Basic Information
| Provider Information | |||||||||
| NPI: | 1285628552 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JULIA DYCKMAN ANDRUS MEMORIAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ANDRUS CHILDRENS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1156 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107011108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149653700 | ||||||||
| FaxNumber: | 9149653883 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 GREENRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106051201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149497680 | ||||||||
| FaxNumber: | 9149977942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEL PILAR | ||||||||
| AuthorizedOfficialFirstName: | RAUL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 9149653700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 7257001A | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00355940 | 05 | NY | MEDICAID | 10363 | 01 | HUDSON HEALTH PLAN ID | OTHER | 050309000005 | 01 | NY | INTEGRA FIDELIS | OTHER | 322149 | 01 | AFFINITY ID | OTHER | 3191813 | 01 | NY | GHI | OTHER |