Provider Demographics
NPI:1619942117
Name:ST ELIZABETH MEDICAL CENTER
Entity Type:Organization
Organization Name:ST ELIZABETH MEDICAL CENTER
Other - Org Name:ST ELIZABETH CERTIFIED HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOERGER PIERSMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-797-9770
Mailing Address - Street 1:14 FOERY DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-6236
Mailing Address - Country:US
Mailing Address - Phone:315-797-9770
Mailing Address - Fax:315-732-7216
Practice Address - Street 1:14 FOERY DR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-6236
Practice Address - Country:US
Practice Address - Phone:315-797-9770
Practice Address - Fax:315-732-7216
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST ELIZABETH MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-20
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3202605251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3202605OtherLICENSE NUMBER
NY00279901Medicaid
NY3202605OtherLICENSE NUMBER