Provider Demographics
NPI:1447973565
Name:GOUVERNEUR HOSPITAL
Entity type:Organization
Organization Name:GOUVERNEUR HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CICCHINELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-261-5102
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2924 COUNTY ROUTE 17
Practice Address - Street 2:
Practice Address - City:DEKALB JCT
Practice Address - State:NY
Practice Address - Zip Code:13630-3136
Practice Address - Country:US
Practice Address - Phone:315-347-3830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health