Provider Demographics
NPI:1316940745
Name:EDWARD JOHN NOBLE HOSPITAL OF GOUVERNEUR NY
Entity type:Organization
Organization Name:EDWARD JOHN NOBLE HOSPITAL OF GOUVERNEUR NY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PATIENT ACCOUNTING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-287-1000
Mailing Address - Street 1:77 W BARNEY ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1040
Mailing Address - Country:US
Mailing Address - Phone:315-287-1000
Mailing Address - Fax:315-535-9207
Practice Address - Street 1:77 W BARNEY ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1040
Practice Address - Country:US
Practice Address - Phone:315-535-9244
Practice Address - Fax:315-535-9305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0134683336C0002X
333600000X
NY4423000C282NC0060X
NY4423000H282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
5805784OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY00354256Medicaid
NY331315Medicare Oscar/Certification
NY330177Medicare Oscar/Certification