Basic Information
| Provider Information | |||||||||
| NPI: | 1598859589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAVATE | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 222 E 41ST ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100176739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122637744 | ||||||||
| FaxNumber: | 2122637721 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 E 41ST ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100176739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122637744 | ||||||||
| FaxNumber: | 2122637721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 161583 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | P3239454 | 01 | OXFORD | OTHER | 2814995 | 01 | AETNA HMO | OTHER | 6016100 | 01 | GHI | OTHER | 161583 | 01 | STATE LICENSE | OTHER | 043695466 | 01 | TAX ID | OTHER | 22621 | 01 | ELDERPLAN | OTHER | 3656599 | 01 | AETNA | OTHER | 548N01 | 01 | BCBS | OTHER | 01602400 | 05 | NY | MEDICAID | 3C6334 | 01 | HEALTHNET | OTHER | 4637585 | 01 | AETNA PPO | OTHER | 548N02 | 01 | BCBS | OTHER | P00072195 | 01 | RAILROAD MEDICARE | OTHER |