=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366683344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. MARY'S HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2009
-----------------------------------------------------
Last Update Date | 11/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4988 STATE HIGHWAY 30
-----------------------------------------------------
City | AMSTERDAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12010-7520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-841-3572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 427 GUY PARK AVE
-----------------------------------------------------
City | AMSTERDAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12010-1054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-841-7434
-----------------------------------------------------
Fax | 518-841-7433
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | JEFFREY METHVEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-841-7101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------