Provider Demographics
NPI:1750462479
Name:CORAM HEALTHCARE CORPORATION OF NEW YORK
Entity type:Organization
Organization Name:CORAM HEALTHCARE CORPORATION OF NEW YORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:
Authorized Official - First Name:VITO
Authorized Official - Middle Name:
Authorized Official - Last Name:PONZIO, JR.
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-672-8631
Mailing Address - Street 1:1675 BROADWAY
Mailing Address - Street 2:SUITE 900
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-4675
Mailing Address - Country:US
Mailing Address - Phone:303-672-8631
Mailing Address - Fax:303-298-0047
Practice Address - Street 1:2949 ERIE BLVD E
Practice Address - Street 2:SUITE 103
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1442
Practice Address - Country:US
Practice Address - Phone:315-425-8028
Practice Address - Fax:315-425-0989
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORAM HEALTHCARE CORPORATION OF NEW YORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9694L003251E00000X, 251F00000X
NYN/A261QI0500X
NY17027989332BP3500X, 333600000X, 3336C0003X, 3336M0002X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9694L003OtherHOME HEALTH AGENCY
NY17027989OtherRX LICENSE
3305011OtherNCPDP
3305011OtherNCPDP
NY9694L003OtherHOME HEALTH AGENCY