Basic Information
| Provider Information | |||||||||
| NPI: | 1548319254 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATHOLIC MEDICAL CENTER OF BROOKLYN AND QUEENS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAINT MARYS HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 W 33RD ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100012603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123564419 | ||||||||
| FaxNumber: | 2123564434 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 BUFFALO AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112132421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182213000 | ||||||||
| FaxNumber: | 2123564434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | YORKE | ||||||||
| AuthorizedOfficialFirstName: | DOLLYANN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 2123564419 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 7001025H | NY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00729373 | 05 | NY | MEDICAID |