Provider Demographics
NPI:1639225816
Name:ST. CHARLES HOSPITAL
Entity Type:Organization
Organization Name:ST. CHARLES HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ANP
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:VITACCO
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:631-474-6975
Mailing Address - Street 1:2 SHELTER HARBOR CT
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2202
Mailing Address - Country:US
Mailing Address - Phone:631-886-1668
Mailing Address - Fax:
Practice Address - Street 1:2 SHELTER HARBOR CT
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2202
Practice Address - Country:US
Practice Address - Phone:631-886-1668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303866-1282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital