1013964170 NPI number — PEDERSON-KRAG CENTER INC

Table of content: (NPI 1013964170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013964170 NPI number — PEDERSON-KRAG CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDERSON-KRAG CENTER 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:
1013964170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
142-02 20TH AVENUE
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
FLUSHING
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-559-0555
Provider Business Mailing Address Fax Number:
718-445-7111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 HORIZON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11743-4436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-920-8000
Provider Business Practice Location Address Fax Number:
631-920-8167
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIVERA-HERRERA
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF FINANCE FOR CLINICAL SERVICES
Authorized Official Telephone Number:
347-542-4217

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00337004 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01819272 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040403001029 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: W02691 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0007155064 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02717417 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0007525706 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 002875 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1042840-8842 . This is a "BEACON HEALTH STRATEGIES" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 11662 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01934014 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3189305 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: ANC1285 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0007632069 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 001728 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 038080 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: DA1829 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01556532 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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