Healthcare Provider Details

I. General information

NPI: 1598851545
Provider Name (Legal Business Name): FAXTON ST LUKES HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 PERIMETER RD STE. 140
ROME NY
13441
US

IV. Provider business mailing address

2209 GENESEE ST/ BUSINESS OFFICE ROOM #315
UTICA NY
13501-5809
US

V. Phone/Fax

Practice location:
  • Phone: 315-334-4786
  • Fax: 315-624-5152
Mailing address:
  • Phone: 315-801-3282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number3202003H
License Number StateNY

VIII. Authorized Official

Name: CODY WHITE
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 315-801-4429