Provider Demographics
NPI:1336339969
Name:CONIFER PARK, INC.
Entity Type:Organization
Organization Name:CONIFER PARK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OP BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-952-8408
Mailing Address - Street 1:PO BOX 10092
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-5092
Mailing Address - Country:US
Mailing Address - Phone:518-952-8408
Mailing Address - Fax:518-399-6860
Practice Address - Street 1:79 GLENRIDGE RD
Practice Address - Street 2:COTTAGE #1
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-4523
Practice Address - Country:US
Practice Address - Phone:518-952-8121
Practice Address - Fax:518-952-8287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081110730261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid
NY52320AMedicare PIN