1184844870 NPI number — SOUTH ELLIOT SOUTH PORTLAND MEDICAL COMPREHENSIVE MEDICAL CENTER

Table of content: (NPI 1184844870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184844870 NPI number — SOUTH ELLIOT SOUTH PORTLAND MEDICAL COMPREHENSIVE MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH ELLIOT SOUTH PORTLAND MEDICAL COMPREHENSIVE MEDICAL CENTER
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:
CAMILLE PHILIPPE
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:
1184844870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
GPO 27007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10087-7007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-858-5088
Provider Business Mailing Address Fax Number:
718-858-5278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
739 FULTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11217-1560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-858-5088
Provider Business Practice Location Address Fax Number:
718-858-5278
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PHILIPPE
Authorized Official First Name:
CAMILLE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
718-858-5088

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  147143 , 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: 0102306 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 209917 . This is a "WELLCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5C4093 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5038C1 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00924438 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50013 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10201320 . This is a "AMERIGROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 147143 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 650251 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: BKX033703 . This is a "AMERICHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2664504 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 72468 . This is a "GHI-HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5998068 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 147143C17 . This is a "HEALTHFIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 170899 . This is a "ELDERPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2835366 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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