Provider Demographics
NPI:1992186852
Name:NORTHWAY SPC LLC
Entity Type:Organization
Organization Name:NORTHWAY SPC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KASANDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:518-371-6772
Mailing Address - Street 1:1596 ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:HALFMOON
Mailing Address - State:NY
Mailing Address - Zip Code:12065-4303
Mailing Address - Country:US
Mailing Address - Phone:518-371-6772
Mailing Address - Fax:518-288-2835
Practice Address - Street 1:1596 ROUTE 9
Practice Address - Street 2:
Practice Address - City:HALFMOON
Practice Address - State:NY
Practice Address - Zip Code:12065
Practice Address - Country:US
Practice Address - Phone:518-322-7720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4552201R261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
33C0001159Medicare UPIN