Basic Information
| Provider Information | |||||||||
| NPI: | 1043619349 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMARITAN DAYTOP VILLAGE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAMARITAN VILLAGE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 W 125TH ST | ||||||||
| Address2: | 10TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128644128 | ||||||||
| FaxNumber: | 2126629193 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 W 125TH ST | ||||||||
| Address2: | 10TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128644128 | ||||||||
| FaxNumber: | 2126629193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2014 | ||||||||
| LastUpdateDate: | 04/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | MADRAY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF HEALTH SERVICES & COMMUNITY B | ||||||||
| AuthorizedOfficialTelephone: | 7182062000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 00245309 | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 139682283 | 05 | NY | MEDICAID |