=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184654212
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JOSEPH'S HOSPITAL HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 11/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4105 MEDICAL CENTER DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13066-6636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-329-7200
-----------------------------------------------------
Fax | 315-329-7203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 PROSPECT AVE
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13203-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-448-5880
-----------------------------------------------------
Fax | 315-448-6161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF FISCAL AFFAIRS, CFO
-----------------------------------------------------
Name | MR. MICHAEL SHAFFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-448-5880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------