Provider Demographics
NPI:1710965124
Name:MERCY HOSPITAL OF WATERTOWN UNITED STATES CATHOLIC CONFERENCE
Entity Type:Organization
Organization Name:MERCY HOSPITAL OF WATERTOWN UNITED STATES CATHOLIC CONFERENCE
Other - Org Name:GENESIS HEALTHCARE OF NEW YORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DPS/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:315-782-0415
Mailing Address - Street 1:199 PRATT ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4349
Mailing Address - Country:US
Mailing Address - Phone:315-782-0415
Mailing Address - Fax:315-786-0417
Practice Address - Street 1:199 PRATT ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4349
Practice Address - Country:US
Practice Address - Phone:315-782-0415
Practice Address - Fax:315-786-0417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal DialysisGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01226553Medicaid
113538582OtherCOMM
337254OtherTRICARE
NY344246OtherGHI VALUE OPTIONS
113538582OtherTRICARE
113538582OtherCOMM INS
P014001500OtherBC ROCHESTER
NYC52892AOther1ST UNITED AMERICAN
113538582OtherCOMM
NY344246OtherGHI VALUE OPTIONS
=========OtherTRICARE
113538582OtherTRICARE
NY52892AMedicare ID - Type Unspecified