Provider Demographics
NPI:1093854564
Name:COUNTY OF OTSEGO
Entity type:Organization
Organization Name:COUNTY OF OTSEGO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:REITZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:607-544-2684
Mailing Address - Street 1:128 PHOENIX MILLS CROSS RD
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-5716
Mailing Address - Country:US
Mailing Address - Phone:607-544-2684
Mailing Address - Fax:607-544-2716
Practice Address - Street 1:128 PHOENIX MILLS CROSS RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-5716
Practice Address - Country:US
Practice Address - Phone:607-544-2684
Practice Address - Fax:607-544-2716
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF OTSEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-05
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3824901L251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01204053Medicaid
NY337054Medicare ID - Type UnspecifiedMEDICARE