1477218089 NPI number — MD ALLY SERVICES, PA

Table of content: (NPI 1477218089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477218089 NPI number — MD ALLY SERVICES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MD ALLY SERVICES, PA
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:
MD ALLY TELEHEALTH SERVICES, PA
Provider Other Organization Name Type Code:
4
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:
1477218089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
348 W 57TH ST STE 180
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:
10019-3702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-350-2116
Provider Business Mailing Address Fax Number:
866-326-5428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7900 OAK LN STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33016-6001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-212-1114
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/08/2021

Additional Information

Authorized Official

Authorized Official Last Name:
FIELDS
Authorized Official First Name:
SHANEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OFFICER
Authorized Official Telephone Number:
212-287-4250

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 147196 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 114428800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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