Basic Information
| Provider Information | |||||||||
| NPI: | 1396146221 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF NY OFFICE OF PAYROLL ADM C/O OFFICE OF PAYROLL ADMIN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NYC DEPT. OF HEALTH AND MENTAL HYGIENE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4209 28TH ST | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111014130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3473966234 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4209 28TH ST | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111014130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3473966234 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2014 | ||||||||
| LastUpdateDate: | 09/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BASSETT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | COMMISSIONER | ||||||||
| AuthorizedOfficialTelephone: | 3473964100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 395611 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.