1578623617 NPI number — UPSTATE CEREBRAL PALSY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578623617 NPI number — UPSTATE CEREBRAL PALSY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UPSTATE CEREBRAL PALSY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UNITED CEREBRAL PALSY
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578623617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1020 MARY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UTICA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13501-1930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-724-6907
Provider Business Mailing Address Fax Number:
315-733-0791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 MARY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UTICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13501-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-724-6907
Provider Business Practice Location Address Fax Number:
315-733-0791
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DECONDO
Authorized Official First Name:
GENO
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
315-724-6907

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  00474180 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00474180 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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