Basic Information
| Provider Information | |||||||||
| NPI: | 1477764496 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTHCARE NETWORK, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MADISON AVE | ||||||||
| Address2: | FLOOR 5 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100101600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125452439 | ||||||||
| FaxNumber: | 6463120481 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 MADISON AVE | ||||||||
| Address2: | FLOOR 6 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100101600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125452439 | ||||||||
| FaxNumber: | 6463120481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 04/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | DJIBO | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 2125452439 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 000695941 | 05 | NY | MEDICAID |