1043232143 NPI number — GRACE FAMILY MEDICAL PRACTICE PC

Table of content: (NPI 1043232143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043232143 NPI number — GRACE FAMILY MEDICAL PRACTICE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE FAMILY MEDICAL PRACTICE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043232143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1222 E 96TH ST
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11236-3903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-257-3355
Provider Business Mailing Address Fax Number:
718-257-4562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1222 E 96TH ST
Provider Second Line Business Practice Location Address:
2ND FL
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11236-3903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-257-3355
Provider Business Practice Location Address Fax Number:
718-257-4562
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHERIDAN
Authorized Official First Name:
BERNADETTE
Authorized Official Middle Name:
LIZINA
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
718-257-3355

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  149698 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0576775 . This is a "AETNA HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 080412000004 . This is a "FIDELISCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 172447 . This is a "WELLCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000109940101 . This is a "HEALTH PLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1P1174 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 08P6021 . This is a "NEW YORK PRESBYTERIAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 149698 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5995872 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03803192 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043232143 . This is a "HEALTHCARE PARTNERS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1043232143 . This is a "EMBLEM HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 115438 . This is a "GHI HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 149698-A16 . This is a "HEALTHFIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 311913 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5760228 . This is a "AETNA COM" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 160955 . This is a "ELDER PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5462A1 . This is a "EMPIRE BC BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P1078363 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00778863 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0901918 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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