1649254806 NPI number — AMERIGROUP NEW YORK, LLC

Table of content: (NPI 1649254806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649254806 NPI number — AMERIGROUP NEW YORK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERIGROUP NEW YORK, LLC
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:
1649254806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 W 31ST ST
Provider Second Line Business Mailing Address:
5TH FLOOR
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10001-2727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-563-5570
Provider Business Mailing Address Fax Number:
212-563-5975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 W 31ST ST
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10001-2727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-563-5570
Provider Business Practice Location Address Fax Number:
212-563-5975
Provider Enumeration Date:
12/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAYTAIAN
Authorized Official First Name:
PETER
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
212-563-5570

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  04-008 , 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: 01617894 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04-008 . This is a "DOH HMO NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02644562 . This is a "MLTC PROVIDER ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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