MEDICARE: STATE OF NEW YORK COMPTROLLERS OFFICE

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	314000000X	Skilled Nursing Facility	5951300N	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	W39391	OTHER	NY	MEDICARE PTAN

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	:	1457348369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF NEW YORK COMPTROLLERS OFFICE

Provider Business Mailing Address
First Line	:	4334 COUNTY ROAD 32
Second Line	:
City	:	OXFORD
State	:	NY
Zip	:	13830-4101
Country	:	US
Telephone Number	:	914-788-6000
Fax Number	:	914-788-6110

Provider Business Practice Location Address
First Line	:	2090 ALBANY POST RD
Second Line	:
City	:	MONTROSE
State	:	NY
Zip	:	10548-1454
Country	:	US
Telephone Number	:	914-788-6000
Fax Number	:	914-788-6110

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	NANCY BAA-DANSO
Credential	:	ADMINISTRATION
Telephone Number	:	914-788-6003

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	01/15/2015

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Directions to “STATE OF NEW YORK COMPTROLLERS OFFICE ” Practice Location

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