Basic Information
| Provider Information | |||||||||
| NPI: | 1295108025 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH PROJECT INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CALLEN-LORDE BRONX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 356 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100114401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122717200 | ||||||||
| FaxNumber: | 2122718128 | ||||||||
| Practice Location | |||||||||
| Address1: | 3144 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104514629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122717200 | ||||||||
| FaxNumber: | 2122718128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2015 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 2122717269 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 571052 | 01 | MEDICARE | OTHER | 04626028 | 05 | NY | MEDICAID |