Provider Demographics
NPI:1679668800
Name:FAXTON-ST. LUKES HEALTHCARE
Entity Type:Organization
Organization Name:FAXTON-ST. LUKES HEALTHCARE
Other - Org Name:MOHAWK VALLEY HEALTH SYSTEM INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR CYCLE REVENUE
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-801-4429
Mailing Address - Street 1:2209 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-801-4238
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-624-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAXTON-ST. LUKES HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-04
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3202003H273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
33S044Medicare Oscar/Certification