NPIMap

Organization Active NPI

Hudson Headwaters Health Network

  • Primary Care Clinic/Center
  • Fort Edward, NY
National Provider Identifier
1124320247
Registry record updated Feb 23, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
HUDSON HEADWATERS HEALTH NETWORK
Practice address
48 East St
Fort Edward, NY 12828-1811
Phone
(518) 824-8630
Fax
(518) 824-2302
NPI assigned
Nov 22, 2010
Last updated
Feb 23, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
HUDSON HEADWATERS HEALTH NETWORKAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 23, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Laura Pasco
Title
Executive VP, Cfo
Phone
(518) 761-0300

Specialties & licenses 10

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
PodiatristGroup: 193200000X MULTI-SPECIALTY GROUP 213E00000X
Federally Qualified Health Center (FQHC) 261QF0400X
Primary Care Clinic/Center 261QP2300X Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X
Family Health Clinical Nurse SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 364SF0001X

Addresses

Primary practice location

48 East St
Fort Edward, NY 12828-1811

Mailing address

9 Carey Rd
Queensbury, NY 12804-7880
Phone (518) 761-0300

Other identifiers 1

IdentifierTypeStateIssuer
03298482MedicaidNY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031117000239 NY Part B Supplier - Clinic/Group Practice 7416861208 Receives reassigned benefits from 266 practitioners
27 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Tupper Lake, NY; Warrensburg, NY; Ticonderoga, NY; Schroon Lake, NY; Saranac Lake, NY; Salem, NY; Queensbury, NY; Plattsburgh, NY…
O20110524000227 NY Part A Provider - Federally Qualified Health Center (FQHC) 7416861208 Practice locations: Fort Edward, NY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124320247. Details of each certification follow.

Federally qualified health center certification: CCN 331026

Legal name
HUDSON HEADWATERS HEALTH NETWORK
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 13, 2011
Last certification
Jul 13, 2011
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jul 15, 1981 in NY
Enrollment address
48 East St
Fort Edward, NY 12828-1811
Related CCNs
331850

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs on the same Medicare enrollment 27

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 27

National Provider Directory

National Provider Directory
Tax ID family
Hudson Headwaters HLTH43 organizations share this tax ID, including this one
Part of
Hudson Headwaters HLTH

Other organizations with this tax ID 42

Organizations that report the same tax identification number in the National Provider Directory.

View all 42

Ownership & related parties

All disclosed owners & managing parties 26

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kristina Hermance Individual Corporate OfficerVP, Logistics Jul 23, 2023
Stephen T Shafer Individual Corporate DirectorBoard Member Jul 25, 2024
Linda Spokane Individual Corporate OfficerPresident & Program Director, Pace Oct 23, 2017
Tracy Mills Individual Corporate OfficerExecutive VP, Network Strategy Jan 3, 2022
Vicki Demarse-Giroux Individual Corporate DirectorBoard Member Nov 18, 2021
Kevin Dougrey Individual Corporate OfficerVP, Medical Staff Operations Aug 31, 2020
David Tucker Slingerland Individual Corporate OfficerCeo Jun 1, 2014
Laura S Pasco Individual Corporate OfficerExecutive VP, Finance & Cfo Sep 19, 2022
W-2 Managing EmployeeExecutive VP, Finance & Cfo Jan 14, 2024
Thomas Dodd Individual Corporate DirectorBoard Member, Vice-Chairperson Nov 18, 2021
Jill Coombes Individual Corporate OfficerVP, Compliance & Cco Apr 5, 2020
Deana Ketchum Individual Corporate DirectorBoard Member, at Large Member Feb 24, 2022
Jessica Rubin Individual Corporate OfficerVP, Chief Impact Officer Apr 5, 2020
Christine a Rowe-Button Individual Corporate DirectorBoard Member, Secretary Nov 18, 2021
James J Morris Individual Corporate DirectorBoard Member, Treasurer Feb 25, 2016
Robert Nemer Individual Corporate DirectorBoard Member Nov 18, 2021
Justin Miller Individual Corporate OfficerEvp, Chief Information Officer Jan 15, 2024
Susan Corney Individual Corporate OfficerExecutive VP, Human Resources Sep 6, 2017
William M Borgos Individual Corporate OfficerChief Medical Officer Oct 1, 2019
Darren Woods Individual Corporate DirectorBoard Member Feb 16, 2023
Matthew Henderson Individual Corporate OfficerEvp, General Counsel Dec 29, 2019
Patricia a Auer Individual Corporate DirectorBoard Member Feb 25, 2021
Cathleen Traver Individual Corporate OfficerVP, Planning and Grants Sep 18, 2023
Brittany Silvestri Individual Corporate OfficerEvp, Chief Operating Officer Aug 8, 2021
Maureen Poole Individual Corporate OfficerVP, Nursing Oct 3, 2021
Peter Reale Individual Corporate DirectorBoard Member Feb 25, 2016
Donna Nichols Individual Corporate DirectorBoard Member, Chairperson Jun 28, 2018

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1290384000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708646400000",
    "number": "1124320247",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9 CAREY RD",
            "city": "QUEENSBURY",
            "state": "NY",
            "postal_code": "128047880",
            "telephone_number": "518-761-0300",
            "fax_number": "518-824-2388"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "48 EAST ST",
            "city": "FORT EDWARD",
            "state": "NY",
            "postal_code": "128281811",
            "telephone_number": "518-824-8630",
            "fax_number": "518-824-2302"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HUDSON HEADWATERS HEALTH NETWORK",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "HUDSON HEADWATERS HEALTH NETWORK",
        "enumeration_date": "2010-11-22",
        "last_updated": "2024-02-23",
        "certification_date": "2024-02-23",
        "status": "A",
        "authorized_official_last_name": "PASCO",
        "authorized_official_first_name": "LAURA",
        "authorized_official_title_or_position": "EXECUTIVE VP, CFO",
        "authorized_official_telephone_number": "518-761-0300"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "213E00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Podiatrist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "364SF0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Clinical Nurse Specialist, Family Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "03298482",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Edward, NY

Sources for this page

Verify at the official NPI Registry.