Basic Information
| Provider Information | |||||||||
| NPI: | 1598809618 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OMRDD-BFFY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 191 JORALEMON ST | ||||||||
| Address2: | 9TH FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112014306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187226038 | ||||||||
| FaxNumber: | 7187226219 | ||||||||
| Practice Location | |||||||||
| Address1: | 1469 FLATBUSH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112102428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182534477 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CORRADO | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 7187226123 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | NY | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 01996107 | 05 | NY | MEDICAID |