1578630604 NPI number — NYSARC INC NYC CHAPTER

Table of content: (NPI 1578630604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578630604 NPI number — NYSARC INC NYC CHAPTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NYSARC INC NYC CHAPTER
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:
1578630604
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:
83 MAIDEN LN
Provider Second Line Business Mailing Address:
11 TH FLOOR
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10038-4812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-780-2631
Provider Business Mailing Address Fax Number:
212-777-5893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 DITMAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11218-6031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-780-2631
Provider Business Practice Location Address Fax Number:
212-777-5893
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDSMITH
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
212-780-2692

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6291458 . This is a "NYS OMRDD OPERATING CERT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01394256 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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