Provider Demographics
NPI:1528108974
Name:GOUVERNEUR HEALTHCARE SERVICES
Entity type:Organization
Organization Name:GOUVERNEUR HEALTHCARE SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MENDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGLER
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ,
Authorized Official - Phone:212-238-7663
Mailing Address - Street 1:227 MADISON ST
Mailing Address - Street 2:PHARMACY FIRST FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-7537
Mailing Address - Country:US
Mailing Address - Phone:212-238-7071
Mailing Address - Fax:212-238-7009
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:PHARMACY FIRST FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7071
Practice Address - Fax:212-238-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0301112261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00243352Medicaid
NY00246084Medicaid
NY013844OtherGOUVERNEUR PHARMACY LIC#
NY0301112OtherSTATE NARCOTICS LIC#
NY00343288Medicaid
NY00343288Medicaid