Provider Demographics
NPI:1487785382
Name:CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER
Entity type:Organization
Organization Name:CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-562-7055
Mailing Address - Street 1:PO BOX 2868
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-0259
Mailing Address - Country:US
Mailing Address - Phone:518-561-2000
Mailing Address - Fax:518-561-0881
Practice Address - Street 1:75 BEEKMAN ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1438
Practice Address - Country:US
Practice Address - Phone:518-561-2000
Practice Address - Fax:518-561-0881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0901001H261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000400019000OtherBLUE SHIELD NENY
NY90031OtherMVP
NY00318814Medicaid
NY10013988OtherCDPHP
NY61101OtherGHI-NYC
NY330250OtherEXCELLUS
NY00919OtherEMPIRE
NY60054OtherAETNA
NY00919OtherUHC
NY13551OtherGHI-FHP
NY00919OtherEMPIRE
NY13551OtherGHI-FHP
NY00318814Medicaid
NY=========OtherRMSCO