Basic Information
| Provider Information | |||||||||
| NPI: | 1528013695 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYU LUTHERAN MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 3RD AVE | ||||||||
| Address2: | LUTHERAN MEDICAL CENTER-MANAGED CARE DEPT | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112203702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186307103 | ||||||||
| FaxNumber: | 7186307437 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 55TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112202559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186307000 | ||||||||
| FaxNumber: | 7186307437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | DELLACERRA | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF MANAGED CARE & REVENUE COMPLI | ||||||||
| AuthorizedOfficialTelephone: | 7186307103 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | V.P. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 7001019H | NY | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 00243729 | 05 | NY | MEDICAID | 001841 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | H04049 | 01 | NY | OXFORD | OTHER | 3189449 | 01 | NY | GHI | OTHER | F0065 | 01 | NY | HIP | OTHER | 44800 | 01 | NY | WELLCARE | OTHER | 90011 | 01 | NY | ELDERPLAN | OTHER |