Basic Information
| Provider Information | |||||||||
| NPI: | 1013291335 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANTHONY L. JORDAN HEALTH CORPORATION | ||||||||
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| OtherOrganizationName: | BROWN SQUARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 82 HOLLAND ST | ||||||||
| Address2: | ALJHC | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146052131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854235800 | ||||||||
| FaxNumber: | 5854232890 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 LAKE AVE | ||||||||
| Address2: | BROWN SQUARE CENTER | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852546480 | ||||||||
| FaxNumber: | 5852541092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 10/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | HARBIN | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5854235800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ANTHONY L. JORDAN HEALTH CORPORATION | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 2701211R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 16467A | 01 | NY | MEDICARE PART B | OTHER | 6613 | 01 | NY | BLUE CROSS OF ROCHESTER | OTHER | 331838 | 01 | NY | MEDICARE PART A | OTHER | G0187295590 | 01 | NY | BLUE CHOICE OF ROCHESTER | OTHER | 03800906 | 05 | NY | MEDICAID |