Basic Information
| Provider Information | |||||||||
| NPI: | 1548347719 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAMARITAN VILLAGE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 138-02 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182062000 | ||||||||
| FaxNumber: | 7182064055 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WEST 125TH STREET | ||||||||
| Address2: | 11TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128659182 | ||||||||
| FaxNumber: | 2126629193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 09/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | APPLE | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP/COO | ||||||||
| AuthorizedOfficialTelephone: | 7182062000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 080911571 | NY | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 02718096 | 05 | NY | MEDICAID | 080911571 | 01 | NY | OASAS LICENSED OUTPATIENT | OTHER |