1104920313 NPI number — SUFFOLK COUNTY DEPT OF HEALTH SERVICES

Table of content: (NPI 1104920313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104920313 NPI number — SUFFOLK COUNTY DEPT OF HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUFFOLK COUNTY DEPT OF HEALTH SERVICES
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:
RIVERHEAD MENTAL HEALTH CLINIC
Provider Other Organization Name Type Code:
5
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:
1104920313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 SUNRISE HWY
Provider Second Line Business Mailing Address:
SUITE 124, PO BOX 9006
Provider Business Mailing Address City Name:
GREAT RIVER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11739-1001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-854-0196
Provider Business Mailing Address Fax Number:
631-854-0198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERHEAD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11901-3393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-852-1440
Provider Business Practice Location Address Fax Number:
631-852-1448
Provider Enumeration Date:
09/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TOMARKEN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
L
Authorized Official Title or Position:
COMMISSIONER
Authorized Official Telephone Number:
631-854-0100

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  6919109A , 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: 00688179 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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