MEDICARE: CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336I0012X	Institutional Pharmacy	011772	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2063511	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073534046
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Provider Business Mailing Address
First Line	:	75 BEEKMAN ST
Second Line	:
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-1438
Country	:	US
Telephone Number	:	518-562-7557
Fax Number	:	518-562-7183

Provider Business Practice Location Address
First Line	:	214 CORNELIA ST
Second Line	:
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-2317
Country	:	US
Telephone Number	:	518-562-7155
Fax Number	:	518-562-7183

Authorized Official
Title or Position	:	PRESIDENT/COO
Name	:	MICHELLE LEBEAU
Credential	:
Telephone Number	:	518-562-7055

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	02/21/2024

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