1447235833 NPI number — MED-PSYCH SERVICE

Table of content: MISS COLLEEN ELIZABETH FORTINE LPN (NPI 1245676964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447235833 NPI number — MED-PSYCH SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED-PSYCH SERVICE
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:
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:
1447235833
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:
43 HIGH POINT CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RYE BROOK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10573-1092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-202-4949
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE GATE WAY PLAZA
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
PORT CHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-202-4949
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NAMIN
Authorized Official First Name:
SAMAD
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
914-202-4949

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  209565 , 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: 02243456 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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