1083197719 NPI number — SUN RIVER HEALTH INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083197719 NPI number — SUN RIVER HEALTH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUN RIVER HEALTH INC
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:
6
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:
1083197719
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5036
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE PLAINS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10602-5036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-734-8800
Provider Business Mailing Address Fax Number:
914-734-8786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 WESTCHESTER AVENUE
Provider Second Line Business Practice Location Address:
WESTCHESTER SQUARE HEALTH CENTER
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10461-3585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-681-8700
Provider Business Practice Location Address Fax Number:
718-299-1420
Provider Enumeration Date:
09/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MCKINNEY
Authorized Official First Name:
EMMA
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CREDENTIALING SUPERVISOR
Authorized Official Telephone Number:
845-745-3611

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  5901200R , 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: W38731 . This is a "GROUP MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00473038 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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