Healthcare Provider Details

I. General information

NPI: 1427077700
Provider Name (Legal Business Name): HUDSON HEADWATERS HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1448 ROUTE 9
SOUTH GLENS FALLS NY
12803
US

IV. Provider business mailing address

1 BROAD STREET PLZ PO BOX 357
GLENS FALLS NY
12801-4390
US

V. Phone/Fax

Practice location:
  • Phone: 518-761-6961
  • Fax: 518-761-1006
Mailing address:
  • Phone: 518-761-0300
  • Fax: 518-745-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number165448
License Number StateNY

VIII. Authorized Official

Name: ERIC BURTON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 518-761-0300