Basic Information
| Provider Information | |||||||||
| NPI: | 1285946780 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW YORK-PRESBYTERIAN HOSPITAL/CENTER FOR SPECIAL STUDIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100111913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127467175 | ||||||||
| FaxNumber: | 2127467197 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100111913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127467175 | ||||||||
| FaxNumber: | 2127467197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2010 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | PEREZ | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | VANNY | ||||||||
| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 2127467175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 076514 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 00243518 | 05 | NY | MEDICAID |