Basic Information
| Provider Information | |||||||||
| NPI: | 1265476907 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROOKDALE HOSPITAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BROOKDALE PLZ STE 666 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182405811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 BROOKDALE PLZ | ||||||||
| Address2: | 2 CHC | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182405015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 10/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | SALVO | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7182405811 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROOKDALE HOSPITAL MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 00610013 | 05 | NY | MEDICAID |