1790164317 NPI number — WYCKOFF DOCTORS

Table of content: JUDITH MCCRONE COPLEY LICSW (NPI 1962784959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790164317 NPI number — WYCKOFF DOCTORS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYCKOFF DOCTORS
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:
1790164317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
374 STOCKHOLM STREET
Provider Second Line Business Mailing Address:
WYCKOFF PROFESSIONAL MEDICAL SERVICES, PC - FACULTY PRA
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11237-4006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-963-7676
Provider Business Mailing Address Fax Number:
718-963-6667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 DEKALB AVENUE
Provider Second Line Business Practice Location Address:
WYCKOFF DOCTORS
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11237-3906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-963-7676
Provider Business Practice Location Address Fax Number:
718-963-6667
Provider Enumeration Date:
05/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
VUTRANO
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
718-963-6702

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03722025 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com