Provider Demographics
NPI:1922699842
Name:CLAXTON HEPBURN MEDICAL CENTER
Entity Type:Organization
Organization Name:CLAXTON HEPBURN MEDICAL CENTER
Other - Org Name:CLAXTON HEPBURN WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-713-5202
Mailing Address - Street 1:214 KING ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1142
Mailing Address - Country:US
Mailing Address - Phone:315-713-5354
Mailing Address - Fax:
Practice Address - Street 1:214 KING ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1142
Practice Address - Country:US
Practice Address - Phone:315-713-5354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAXTON HEPBURN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-02
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8231001AOtherNYS OFFICE OF MENTAL HEALTH ARTICLE 31 LICENSURE