Basic Information
| Provider Information | |||||||||
| NPI: | 1326374810 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACT & ICM/SCM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143653501 | ||||||||
| FaxNumber: | 9146324938 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143653501 | ||||||||
| FaxNumber: | 9146324938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2009 | ||||||||
| LastUpdateDate: | 10/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | CONNOLLY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9143653501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE MOUNT VERNON HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 5903000H | NY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 02135573 | 05 | NY | MEDICAID | 02375088 | 05 | NY | MEDICAID |