Basic Information
| Provider Information | |||||||||
| NPI: | 1417352709 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUN RIVER HEALTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HRHC SHIRLEY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5036 | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106025036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147348800 | ||||||||
| FaxNumber: | 9147348786 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | SHIRLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119672114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314903040 | ||||||||
| FaxNumber: | 6314903055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2014 | ||||||||
| LastUpdateDate: | 03/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIPTON | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP INFO/PRACTICE MGMT SYSTEMS | ||||||||
| AuthorizedOfficialTelephone: | 9143842375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUN RIVER HEALTH INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 261QF0400X | 5901200R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 00473038 | 05 | NY | MEDICAID |