Provider Demographics
NPI:1609928969
Name:OTSELIC VALLEY CSD (GEORGETOWN-SOUTH OTSELIC CSD)
Entity Type:Organization
Organization Name:OTSELIC VALLEY CSD (GEORGETOWN-SOUTH OTSELIC CSD)
Other - Org Name:GEORGETOWN SOUTH OTSELIC CSD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRINCIPAL/BUSINESS ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:BERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-653-7218
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:125 COUNTY ROAD 13A
Mailing Address - City:SOUTH OTSELIC
Mailing Address - State:NY
Mailing Address - Zip Code:13155-0161
Mailing Address - Country:US
Mailing Address - Phone:315-653-7218
Mailing Address - Fax:315-653-7500
Practice Address - Street 1:125 COUNTY ROAD 13A
Practice Address - Street 2:
Practice Address - City:SOUTH OTSELIC
Practice Address - State:NY
Practice Address - Zip Code:13155-0161
Practice Address - Country:US
Practice Address - Phone:315-653-7218
Practice Address - Fax:315-653-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01390523Medicare ID - Type Unspecified