1689715476 NPI number — UNIVERSITY PHYSICIANS OF BROOKLYN, INC.

Table of content: (NPI 1689715476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689715476 NPI number — UNIVERSITY PHYSICIANS OF BROOKLYN, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY PHYSICIANS OF BROOKLYN, 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:
UPB CHILDREN'S MENTAL HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1689715476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 CLARKSON AVE
Provider Second Line Business Mailing Address:
MSC# 80
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11203-2056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-613-8481
Provider Business Mailing Address Fax Number:
718-613-8498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
445 LENOX RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11203-2017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-270-2036
Provider Business Practice Location Address Fax Number:
718-270-3910
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUIDICE
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
ENROLLMENT MANAGER
Authorized Official Telephone Number:
718-613-8481

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03888864 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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