Provider Demographics
NPI:1720374093
Name:UPSTATE CEREBRAL PALSY, INC.
Entity Type:Organization
Organization Name:UPSTATE CEREBRAL PALSY, INC.
Other - Org Name:UPSTATE CEREBRAL PALSY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GENO
Authorized Official - Middle Name:
Authorized Official - Last Name:DECON DO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-724-6907
Mailing Address - Street 1:125 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6305
Mailing Address - Country:US
Mailing Address - Phone:315-724-6907
Mailing Address - Fax:315-733-0791
Practice Address - Street 1:336 E STATE ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2026
Practice Address - Country:US
Practice Address - Phone:315-866-2839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02146303Medicaid