Healthcare Provider Details

I. General information

NPI: 1033361340
Provider Name (Legal Business Name): ST LUKE'S CORNWALL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 LAUREL AVE STE 240 FACULTY GROUP PRACTICE ST LUKE'S CORNWALL HOSPITAL
CORNWALL NY
12518-1476
US

IV. Provider business mailing address

21 LAUREL AVE STE 240 FACULTY GROUP PRACTICE ST LUKE'S CORNWALL HOSPITAL
CORNWALL NY
12518-1476
US

V. Phone/Fax

Practice location:
  • Phone: 845-458-4876
  • Fax: 845-458-4560
Mailing address:
  • Phone: 845-458-4876
  • Fax: 845-458-4560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. JILL G BARTON
Title or Position: VICE PRESIDENT OF FINANCE
Credential:
Phone: 845-458-4023