Basic Information
| Provider Information | |||||||||
| NPI: | 1194053645 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE BROOKDALE HOSPITAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BROOKDALE HOSPITAL ORAL SURGEON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BROOKDALE PLZ | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182405741 | ||||||||
| FaxNumber: | 7182406682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BROOKDALE PLZ | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182406281 | ||||||||
| FaxNumber: | 7182406682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PALERMO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7182405815 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0112X | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00243572 | 05 | NY | MEDICAID |