Provider Demographics
NPI:1922230853
Name:CRYSTAL RUN AMBULATORY SURGERY CENTER OF MIDDLETOWN, LLC
Entity Type:Organization
Organization Name:CRYSTAL RUN AMBULATORY SURGERY CENTER OF MIDDLETOWN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PROVIDER RESOURCES
Authorized Official - Prefix:
Authorized Official - First Name:JENNINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEENEY DENARDO
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:845-796-5507
Mailing Address - Street 1:95 CRYSTAL RUN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-7001
Mailing Address - Country:US
Mailing Address - Phone:845-703-6999
Mailing Address - Fax:845-703-6297
Practice Address - Street 1:95 CRYSTAL RUN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-7001
Practice Address - Country:US
Practice Address - Phone:845-703-6999
Practice Address - Fax:845-703-6297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03240397Medicaid
NY03240397Medicaid