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	363A00000X	Physician Assistant	3349	NY

General Provider Information

NPI Number	:	1992719561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUDSON HEADWATERS HEALTH NETWORK

Provider Business Mailing Address
First Line	:	1 BROAD STREET PLZ
Second Line	:	PO BOX 357
City	:	GLENS FALLS
State	:	NY
Zip	:	12801-4390
Country	:	US
Telephone Number	:	518-761-0300
Fax Number	:	518-745-1378

Provider Business Practice Location Address
First Line	:	3767 MAIN ST
Second Line	:
City	:	WARRENSBURG
State	:	NY
Zip	:	12885-1837
Country	:	US
Telephone Number	:	518-623-2844
Fax Number	:	518-623-3416

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	ERIC BURTON
Credential	:
Telephone Number	:	518-761-0300

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	08/22/2020

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