Basic Information
Provider Information | |||||||||
NPI: | 1609985571 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NYSARC INC. SULLIVAN COUNTY CHAPTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SULLIVAN ARC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 162 E BROADWAY | ||||||||
Address2: |   | ||||||||
City: | MONTICELLO | ||||||||
State: | NY | ||||||||
PostalCode: | 127018815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8457961350 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 162 E BROADWAY | ||||||||
Address2: |   | ||||||||
City: | MONTICELLO | ||||||||
State: | NY | ||||||||
PostalCode: | 127018815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8457961350 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 01/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHWARTZ | ||||||||
AuthorizedOfficialFirstName: | J. | ||||||||
AuthorizedOfficialMiddleName: | RICHARD | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8457961350 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | 6206471 | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
ID | Type | State | Issuer | Description | 005365 | 05 | NY |   | MEDICAID |