Provider Demographics
NPI:1447227491
Name:HEALTHALLIANCE MARYS AVENUE CAMPUS
Entity type:Organization
Organization Name:HEALTHALLIANCE MARYS AVENUE CAMPUS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PATIENT ACCOUNTS
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-943-6007
Mailing Address - Street 1:105 MARY'S AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401
Mailing Address - Country:US
Mailing Address - Phone:845-943-6007
Mailing Address - Fax:845-943-6038
Practice Address - Street 1:105 MARY'S AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-943-6007
Practice Address - Fax:845-943-6038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00274020Medicaid
NY10005742OtherCDPHP PROVIDER ID
NY3185OtherGHI PROVIDER ID
NY000302OtherBLUE CROSS PROVIDER NUMBE
NYUV5282OtherMVP PROVIDER ID
NY103185OtherWELLCARE PROVIDER ID
NY6450795OtherAETNA PROVIDER ID
NY000302OtherBLUE CROSS PROVIDER NUMBE