Provider Demographics
NPI:1285698399
Name:PEGGY HYSACK
Entity type:Organization
Organization Name:PEGGY HYSACK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:HYSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-823-1625
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:389 WEST MAIN STREET
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13365
Mailing Address - Country:US
Mailing Address - Phone:315-823-1625
Mailing Address - Fax:315-823-1625
Practice Address - Street 1:389 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NY
Practice Address - Zip Code:13365
Practice Address - Country:US
Practice Address - Phone:315-823-1625
Practice Address - Fax:315-823-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01677518Medicaid
1102970001Medicare NSC