Basic Information
Provider Information | |||||||||
NPI: | 1407129562 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE INSTITUTE FOR FAMILY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILY PRACTICE CENTER OF HYDE PARK | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | CL # 4655 | ||||||||
Address2: | PO BOX 95000 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191954655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004446020 | ||||||||
FaxNumber: | 8452561881 | ||||||||
Practice Location | |||||||||
Address1: | 11 CRUM ELBOW RD | ||||||||
Address2: |   | ||||||||
City: | HYDE PARK | ||||||||
State: | NY | ||||||||
PostalCode: | 125382852 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8452291020 | ||||||||
FaxNumber: | 8452292005 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2012 | ||||||||
LastUpdateDate: | 10/06/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CALMAN | ||||||||
AuthorizedOfficialFirstName: | NEIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 2122065200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | THE INSTITUTE FOR FAMILY HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00903700 | 05 | NY |   | MEDICAID |