1629050208 NPI number — INTREPID OF NEW YORK INC

Table of content: (NPI 1629050208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629050208 NPI number — INTREPID OF NEW YORK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTREPID OF NEW YORK 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:
1629050208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4055 VALLEY VIEW LN
Provider Second Line Business Mailing Address:
5TH FLOOR
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75244-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-445-3750
Provider Business Mailing Address Fax Number:
214-445-3902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212-47 JAMAICA AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR, SUITE 209
Provider Business Practice Location Address City Name:
QUEENS VILLAGE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11428-1632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-776-7760
Provider Business Practice Location Address Fax Number:
718-776-7884
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
214-445-3750

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1067L002 , 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: 02517095 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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