MEDICARE: HUDSON HEADWATERS HEALTH NETWORK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist		NY
2	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073529301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUDSON HEADWATERS HEALTH NETWORK

Provider Business Mailing Address
First Line	:	9 CAREY RD
Second Line	:
City	:	QUEENSBURY
State	:	NY
Zip	:	12804-7880
Country	:	US
Telephone Number	:	518-761-0300
Fax Number	:	518-824-2388

Provider Business Practice Location Address
First Line	:	3761 MAIN ST
Second Line	:
City	:	WARRENSBURG
State	:	NY
Zip	:	12885-1837
Country	:	US
Telephone Number	:	518-623-3918
Fax Number	:	518-623-4330

Authorized Official
Title or Position	:	EXECUTIVE VP, CFO
Name	:	LAURA PASCO
Credential	:
Telephone Number	:	518-761-0300

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	02/23/2024

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