1285680389 NPI number — NYCDOHMH HILLSIDE AVENUE HEALTH CENTER

Table of content: (NPI 1285680389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285680389 NPI number — NYCDOHMH HILLSIDE AVENUE HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NYCDOHMH HILLSIDE AVENUE HEALTH 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:
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:
1285680389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 74
Provider Second Line Business Mailing Address:
125 WORTH STREET RM 901
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10013-4006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-442-8468
Provider Business Mailing Address Fax Number:
212-442-8452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
164 21 HILLSIDE AVENUE
Provider Second Line Business Practice Location Address:
NYCDOHMH HILLSIDE AVENUE HEALTH CENTER
Provider Business Practice Location Address City Name:
JAMAICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11432-4140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-676-2259
Provider Business Practice Location Address Fax Number:
718-262-8885
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMOOK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
ADMINISTRATIVE MANAGER THIRD PARTY
Authorized Official Telephone Number:
212-442-8468

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  7002112R5621 , 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: 00247549 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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