Provider Demographics
NPI:1568471852
Name:KINGSTON AMBULATORY SURGICAL CENTER
Entity Type:Organization
Organization Name:KINGSTON AMBULATORY SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-338-4777
Mailing Address - Street 1:40 HURLEY AVE
Mailing Address - Street 2:SUITE 13
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3739
Mailing Address - Country:US
Mailing Address - Phone:845-338-4777
Mailing Address - Fax:845-339-7339
Practice Address - Street 1:40 HURLEY AVE
Practice Address - Street 2:SUITE 13
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3739
Practice Address - Country:US
Practice Address - Phone:845-338-4777
Practice Address - Fax:845-339-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5501210R261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5501210ROtherNYS DOH LICENSE #
NY178394Medicaid
NYWDW911Medicare PIN