Provider Demographics
NPI:1619124211
Name:ST. MARY'S WOODLAND VILLAGE
Entity Type:Organization
Organization Name:ST. MARY'S WOODLAND VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP NETWORK OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WURTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-268-5520
Mailing Address - Street 1:1 ABELE DR
Mailing Address - Street 2:C/O SCHUYLER RIDGE
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2951
Mailing Address - Country:US
Mailing Address - Phone:518-371-1400
Mailing Address - Fax:518-371-1240
Practice Address - Street 1:1401 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1621
Practice Address - Country:US
Practice Address - Phone:518-268-6263
Practice Address - Fax:518-268-5242
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SETON HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01337622Medicaid