Provider Demographics
NPI:1588819791
Name:CHAUTAUQUA COUNTY DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:CHAUTAUQUA COUNTY DEPARTMENT OF HEALTH
Other - Org Name:PRESCHOOL SUPPORTIVE HEALTH SERVICES PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:INTERIM COMMISSIONER OF HEALTH SERV
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-753-4314
Mailing Address - Street 1:7 N ERIE ST
Mailing Address - Street 2:HRC BLDG, 4TH FLOOR
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-1090
Mailing Address - Country:US
Mailing Address - Phone:716-753-4314
Mailing Address - Fax:716-753-4794
Practice Address - Street 1:7 N ERIE ST
Practice Address - Street 2:HRC BLDG, 4TH FLOOR
Practice Address - City:MAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:14757-1090
Practice Address - Country:US
Practice Address - Phone:716-753-4431
Practice Address - Fax:716-753-4794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01430437Medicaid