Basic Information
| Provider Information | |||||||||
| NPI: | 1396932380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYC HEALTH AND HOSPITALS CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELMURST HOSPITAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | NYC HEALTH & HOSPITALS/ELMHURST | ||||||||
| Address2: | 7901 BROADWAY D1-04 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183345597 | ||||||||
| FaxNumber: | 7183345990 | ||||||||
| Practice Location | |||||||||
| Address1: | NYC HEALTH & HOSPITALS/ELMHURST ACT TEAM | ||||||||
| Address2: | 78-07 41ST AVENUE | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124238700 | ||||||||
| FaxNumber: | 7183345990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2007 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LACAYO | ||||||||
| AuthorizedOfficialFirstName: | MANNY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR ASSOCIATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7183345597 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 02920785 | 05 | NY | MEDICAID |