Basic Information
| Provider Information | |||||||||
| NPI: | 1588907455 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PILGRIM PSYCHIATRIC CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INTENSIVE CASE MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 175 FULTON AVE | ||||||||
| Address2: | |||||||||
| City: | HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115503150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165052003 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 175 FULTON AVE | ||||||||
| Address2: | |||||||||
| City: | HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115503150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165052003 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2013 | ||||||||
| LastUpdateDate: | 03/29/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALZOKM | ||||||||
| AuthorizedOfficialFirstName: | GALAL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTENSIVE CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6317614154 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 146013200 | NY | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 146013200 | 05 | NY | MEDICAID |