Provider Demographics
NPI:1578627865
Name:ALICE HYDE MEDICAL CENTER
Entity Type:Organization
Organization Name:ALICE HYDE MEDICAL CENTER
Other - Org Name:ALICE HYDE DIALYSIS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MACDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-481-2212
Mailing Address - Street 1:133 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-1220
Mailing Address - Country:US
Mailing Address - Phone:518-481-2212
Mailing Address - Fax:
Practice Address - Street 1:133 PARK ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1243
Practice Address - Country:US
Practice Address - Phone:518-481-2212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1624000H282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354114Medicaid
NY00354114Medicaid