Healthcare Provider Details

I. General information

NPI: 1013306059
Provider Name (Legal Business Name): DOWNSTATE CORRECTIONAL FACILTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 RED SCHOOLHOUSE RD
FISHKILL NY
12524-2810
US

IV. Provider business mailing address

PO BOX 445
FISHKILL NY
12524-0445
US

V. Phone/Fax

Practice location:
  • Phone: 845-831-6600
  • Fax: 845-831-6794
Mailing address:
  • Phone: 845-831-6600
  • Fax: 845-831-6794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License NumberF336460-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberF336460-1
License Number StateNY

VIII. Authorized Official

Name: MARIO MALVAROSA
Title or Position: FACILTY HEALTH SERVICES DIRECTOR
Credential: MD
Phone: 845-831-6600