Basic Information
| Provider Information | |||||||||
| NPI: | 1225150030 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITED CEREBRAL PALSY ASSOC OF NYS INC | ||||||||
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| OtherOrganizationName: | CEREBRAL PALSY OF NYS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 W 34TH ST # 15FL | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129475770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 455 MEDINA ST | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103064435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189878331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 09/21/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANDELKOW | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXEC VICE PRES | ||||||||
| AuthorizedOfficialTelephone: | 2129475770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | NY | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 00771559 | 05 | NY | MEDICAID |