Basic Information
Provider Information | |||||||||
NPI: | 1548592348 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OPEN DOOR FAMILY MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 165 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | OSSINING | ||||||||
State: | NY | ||||||||
PostalCode: | 105624702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9145021470 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 351 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT KISCO | ||||||||
State: | NY | ||||||||
PostalCode: | 105493003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9147204214 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/03/2010 | ||||||||
LastUpdateDate: | 02/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAZZOTTA | ||||||||
AuthorizedOfficialFirstName: | MARIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9145021470 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OPEN DOOR FAMILY MEDICAL CENTER, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 5905200R | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.