1104872506 NPI number — NYCDOHMH MOTTHYN CONNECT CMCM

Table of content: (NPI 1104872506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104872506 NPI number — NYCDOHMH MOTTHYN CONNECT CMCM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NYCDOHMH MOTTHYN CONNECT CMCM
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:
1104872506
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:
125 WORTH STREET
Provider Second Line Business Mailing Address:
NYCDOHMH DIV OF DISEASE CONTROL RM 901 BOX 22
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10004-4006
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:
1309 FULTON AVENUE
Provider Second Line Business Practice Location Address:
NYCDOHMH MOTT HAVEN CONNECT CMCM
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10456-2403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-367-2450
Provider Business Practice Location Address Fax Number:
718-367-5112
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 MGR 3D PARTY REVENUE
Authorized Official Telephone Number:
212-442-5468

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  01234413026 , 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: 01234413 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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