Basic Information
| Provider Information | |||||||||
| NPI: | 1316446586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | URBAN HEALTH PLAN, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VIDA GUIDANCE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104592417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185892440 | ||||||||
| FaxNumber: | 7189914516 | ||||||||
| Practice Location | |||||||||
| Address1: | 4419 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183647700 | ||||||||
| FaxNumber: | 7183641513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2018 | ||||||||
| LastUpdateDate: | 02/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | PALOMA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7185892440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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 | W03211 | 01 | NY | OSCAR | OTHER |