Healthcare Provider Details

I. General information

NPI: 1679668800
Provider Name (Legal Business Name): FAXTON-ST. LUKES HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1656 CHAMPLIN AVE
UTICA NY
13502
US

IV. Provider business mailing address

2209 GENESEE ST
UTICA NY
13501-5930
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-6000
  • Fax:
Mailing address:
  • Phone: 315-801-4238
  • Fax: 315-801-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number3202003H
License Number StateNY

VIII. Authorized Official

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