Provider Demographics
NPI: | 1013928159 |
---|---|
Name: | HUDSON HEADWATERS HEALTH NETWORK |
Entity Type: | Organization |
Organization Name: | HUDSON HEADWATERS HEALTH NETWORK |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EXECUTIVE VP OF FINANCE / CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CHRISTOPHER |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | TOURNIER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 518-761-0300 |
Mailing Address - Street 1: | 9 CAREY RD |
Mailing Address - Street 2: | |
Mailing Address - City: | QUEENSBURY |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 12804-7880 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 518-761-0300 |
Mailing Address - Fax: | 518-824-2388 |
Practice Address - Street 1: | 3767 MAIN ST |
Practice Address - Street 2: | |
Practice Address - City: | WARRENSBURG |
Practice Address - State: | NY |
Practice Address - Zip Code: | 12885-1890 |
Practice Address - Country: | US |
Practice Address - Phone: | 518-623-2844 |
Practice Address - Fax: | 518-623-3416 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-08-11 |
Last Update Date: | 2020-01-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 104100000X, 122300000X, 133N00000X, 207Q00000X, 207R00000X, 207V00000X, 208000000X, 208100000X, 213E00000X, 363A00000X, 363L00000X, 367A00000X | |
NY | 5660200R | 261QF0400X |
261QP2300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | Group - Multi-Specialty |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 122300000X | Dental Providers | Dentist | Group - Multi-Specialty | |
No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
No | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 00630039 | Medicaid |