Provider Demographics
NPI:1821229139
Name:DERUYTER HEALTH CENTER
Entity Type:Organization
Organization Name:DERUYTER HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-753-3797
Mailing Address - Street 1:17 MAIN ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-6606
Mailing Address - Country:US
Mailing Address - Phone:607-753-3797
Mailing Address - Fax:607-753-6677
Practice Address - Street 1:5729 STATE ROUTE 13
Practice Address - Street 2:
Practice Address - City:DERUYTER
Practice Address - State:NY
Practice Address - Zip Code:13052-0364
Practice Address - Country:US
Practice Address - Phone:315-852-3318
Practice Address - Fax:315-852-9997
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY331863OtherMEDICARE PTAN