Basic Information
| Provider Information | |||||||||
| NPI: | 1215976113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FEGS FAR ROCKAWAY MNTL HLTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 HUDSON ST | ||||||||
| Address2: | 9TH FL. | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100131009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123668007 | ||||||||
| FaxNumber: | 2123668069 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116914008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183271600 | ||||||||
| FaxNumber: | 7188684792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | WAIZER | ||||||||
| AuthorizedOfficialFirstName: | JONAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2123668024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 6287100A | NY | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 00257805 | 05 | NY | MEDICAID |