NPIMap

Organization Active NPI

Conifer Park, Inc.

  • Substance Use Disorder Rehabilitation Clinic/Center
  • Glenville, NY
National Provider Identifier
1336339969
Registry record updated Dec 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Substance Use Disorder Rehabilitation Clinic/CenterTaxonomy code 261QR0405X
License
081110730 Issued in NY
Legal business name
CONIFER PARK, INC.
Practice address
79 Glenridge Rd
Cottage #1
Glenville, NY 12302-4523
Phone
(518) 952-8121
Fax
(518) 952-8287
NPI assigned
Jul 30, 2007
Last updated
Dec 23, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 23, 2021

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

Authorized official

Name
Tammy Smith
Title
Op Business Manager
Phone
(518) 952-8408

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X 081110730 NY Primary

Addresses

Primary practice location

79 Glenridge Rd
Cottage #1
Glenville, NY 12302-4523

Mailing address

PO Box 10092
Albany, NY 12201-5092
Phone (518) 952-8408

Other identifiers 1

IdentifierTypeStateIssuer
01420800MedicaidNY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040503001584 NY Part B Supplier - Clinic/Group Practice 2769470384 Receives reassigned benefits from 20 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Troy, NY; Schenectady, NY; Rochester, NY; Liverpool, NY; Glenville, NY; Glens Falls, NY; Plattsburgh, NY

Other NPIs on the same Medicare enrollment 8

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

National Provider Directory

National Provider Directory
Tax ID family
Conifer Park Inc9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Locations

80 Sharron Ave
Plattsburgh, NY 12901
Phone (518) 561-1447

Practitioners & affiliated clinicians

Practitioners 61

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.

View all 61

NPI Registry JSON

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

{
    "created_epoch": "1185753600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1640217600000",
    "number": "1336339969",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 10092",
            "city": "ALBANY",
            "state": "NY",
            "postal_code": "122015092",
            "telephone_number": "518-952-8408",
            "fax_number": "518-399-6860"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "79 GLENRIDGE RD",
            "address_2": "COTTAGE #1",
            "city": "GLENVILLE",
            "state": "NY",
            "postal_code": "123024523",
            "telephone_number": "518-952-8121",
            "fax_number": "518-952-8287"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CONIFER PARK, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-30",
        "last_updated": "2021-12-23",
        "certification_date": "2021-12-23",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "TAMMY",
        "authorized_official_title_or_position": "OP BUSINESS MANAGER",
        "authorized_official_telephone_number": "518-952-8408"
    },
    "taxonomies": [
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": "NY",
            "license": "081110730",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01420800",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Glenville, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 23, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.