Hudson Headwaters Health Network
Organization Active NPI Primary Care Clinic/Center · Champlain, NY
NPI 1245285170 · NPPES record last updated Feb 23, 2024
Key facts
- NPI
- 1245285170
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Primary Care Clinic/Center 261QP2300X
- Legal business name
- HUDSON HEADWATERS HEALTH NETWORK
- Practice address
- 828 State Route 11
Champlain, NY 12919-4966 - Phone
- (518) 298-2691
- Fax
- (518) 298-8241
- NPI assigned
- May 22, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- HUDSON HEADWATERS HEALTH NETWORK
Authorized official
- Name
- Laura Pasco
- Title
- Executive VP, Cfo
- Phone
- (518) 761-0300
Owners & managing parties with NPI records 3
-
William M Borgos, MD
-
Christine A Rowe-Button, M.D.
Other NPIs on the same Medicare enrollment 27
Related certifications (CCN) 1
Practitioners 179
-
Danielle M Baker, PA-C
-
Jennifer Lee Lauricella, PA-C
-
Carrie B Miron, PA-C
-
Maurice A Racine, MD
-
Nicole Robinson, MD
-
Sarah Taslima, DPM
-
Kristofer A Abel, PA-C
-
Amanda M Abrams, PA-C
-
Kimberly Dawn Alger, FNP
-
Kristine Blais Alix, FNP
-
Rita Lynn All, FNP
-
Loren M Allen, FNP
-
Glen E Anderson, PA-C
-
Dawn Marie Ashline, FNP
-
Jackie S Avery, DPM
-
Holly E Bachilas, MD
-
Ephraim E Back, MD
-
Nicole A Baker, FNP
-
Alexandra M Barbieri, RD CDN
-
Nicole Marie Bennett, CNM
-
Suzanne E Bergin, DO
-
Elizabeth A Bessette, FNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NY
Federally qualified health center certification: CCN 331059
- Legal name
- HUDSON HEADWATERS HEALTH NETWORK
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Feb 20, 2013
- Last certification
- Feb 20, 2013
- Ownership / control type
- For profit – partnership
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jul 15, 1981 in NY
- Enrollment address
- 828 State Route 11
Champlain, NY 12919-4966 - Related CCNs
- 331850
All disclosed owners & managing parties 26
| Name | Role | Since | Share |
|---|---|---|---|
| Kristina Hermance |
Corporate Officer |
Jul 23, 2023 | |
| Stephen T Shafer |
Corporate Director |
Jul 25, 2024 | |
| Linda Spokane |
Corporate Officer |
Oct 23, 2017 | |
| Tracy Mills |
Corporate Officer |
Jan 3, 2022 | |
| Vicki Demarse-Giroux |
Corporate Director |
Nov 18, 2021 | |
| Kevin Dougrey |
Corporate Officer |
Aug 31, 2020 | |
| David Tucker Slingerland |
Corporate Officer |
Jun 1, 2014 | |
| Laura S Pasco |
Corporate Officer |
Sep 19, 2022 | |
| W-2 Managing Employee |
Jan 14, 2024 | ||
| Thomas Dodd |
Corporate Director |
Nov 18, 2021 | |
| Jill Coombes |
Corporate Officer |
Apr 5, 2020 | |
| Deana Ketchum |
Corporate Director |
Feb 24, 2022 | |
| Jessica Rubin |
Corporate Officer |
Apr 5, 2020 | |
| Christine a Rowe-Button |
Corporate Director |
Nov 18, 2021 | |
| James J Morris |
Corporate Director |
Feb 25, 2016 | |
| Robert Nemer |
Corporate Director |
Nov 18, 2021 | |
| Justin Miller |
Corporate Officer |
Jan 15, 2024 | |
| Susan Corney |
Corporate Officer |
Sep 6, 2017 | |
| William M Borgos |
Corporate Officer |
Oct 1, 2019 | |
| Darren Woods |
Corporate Director |
Feb 16, 2023 | |
| Matthew Henderson |
Corporate Officer |
Dec 29, 2019 | |
| Patricia a Auer |
Corporate Director |
Feb 25, 2021 | |
| Cathleen Traver |
Corporate Officer |
Sep 18, 2023 | |
| Brittany Silvestri |
Corporate Officer |
Aug 8, 2021 | |
| Maureen Poole |
Corporate Officer |
Oct 3, 2021 | |
| Peter Reale |
Corporate Director |
Feb 25, 2016 | |
| Donna Nichols |
Corporate Director |
Jun 28, 2018 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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… |
| O20121228000031 | NY | Part a Provider - Federally Qualified Health Center (FQHC) | 7416861208 | Practice locations: Champlain, NY |
National Provider Directory
- Part of
- Hudson Headwaters HLTH
Locations
481 State Route 11
Champlain, NY 12919
Phone (518) 298-2691
16 3rd St
Ste A
Malone, NY 12953
Phone (518) 481-2401
101 Adirondack Dr
Ste 2
Ticonderoga, NY 12883
Phone (518) 585-6708
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | NY | ||
| Primary Care Clinic/Center | 261QP2300X | Yes |
Addresses
Primary practice location
828 State Route 11
Champlain, NY 12919-4966
Mailing address
9 Carey Rd
Queensbury, NY 12804-7880
Phone (518) 761-0300
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 02384669 | Medicaid | NY |
Other providers in Champlain, NY
- Shahbanoo Ghaffari Zandi
- Finnick Louise Hakamaki
- Samantha Yvonne Harris
- Laurie Ann Harrison
- Peter M Harrison
- Humanware USA Inc
- Jessica S King
- Tyler James King
- Pawel Patryk Klimkiewicz
- KPH Healthcare Services, Inc.
All providers in Champlain, NY · Primary Care Clinic/Center in New York
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 23, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.