Basic Information
| Provider Information | |||||||||
| NPI: | 1437335312 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITED CEREBRAL PALSY ASSOC OF NYS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | HANDICAPPED CHILDRENS ASSN OF SOUTHERN NY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 W 34TH ST FL 15 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129475770 | ||||||||
| FaxNumber: | 2123561348 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072170066 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2008 | ||||||||
| LastUpdateDate: | 01/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | MANDELKOW | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXEC VP | ||||||||
| AuthorizedOfficialTelephone: | 2129475770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 014 | 05 | NY | MEDICAID | 00947324 | 05 | NY | MEDICAID |