Provider Demographics
NPI:1649624941
Name:UPSTATE CEREBRAL PALSY, INC.
Entity type:Organization
Organization Name:UPSTATE CEREBRAL PALSY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GENO
Authorized Official - Middle Name:
Authorized Official - Last Name:DECONDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-724-6907
Mailing Address - Street 1:125 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6305
Mailing Address - Country:US
Mailing Address - Phone:315-724-6907
Mailing Address - Fax:315-733-0791
Practice Address - Street 1:10708 N GAGE RD
Practice Address - Street 2:
Practice Address - City:BARNEVELD
Practice Address - State:NY
Practice Address - Zip Code:13304-2527
Practice Address - Country:US
Practice Address - Phone:315-896-2654
Practice Address - Fax:315-896-2717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6282310261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
55164AMedicare PIN