Provider Demographics
NPI:1972786309
Name:NEW YORK MEDICAID
Entity Type:Organization
Organization Name:NEW YORK MEDICAID
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCARSELLETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-253-7629
Mailing Address - Street 1:10 FOURTH AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021
Mailing Address - Country:US
Mailing Address - Phone:315-253-7629
Mailing Address - Fax:
Practice Address - Street 1:10 FOURTH AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-5106
Practice Address - Country:US
Practice Address - Phone:315-253-7629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137288-1251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care