Basic Information
| Provider Information | |||||||||
| NPI: | 1093789117 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE MOUNT VERNON HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146648000 | ||||||||
| FaxNumber: | 9146648015 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146648000 | ||||||||
| FaxNumber: | 9146648015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 11/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | HASKINS | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9146648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNT VERNON HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01806546 | 05 | NY | MEDICAID |