Basic Information
| Provider Information | |||||||||
| NPI: | 1619136140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN DOOR FAMILY MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OSSINING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105624702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9145021470 | ||||||||
| FaxNumber: | 9147627224 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SLEEPY HOLLOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105912370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146314141 | ||||||||
| FaxNumber: | 9145248594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 03/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | FARRELL | ||||||||
| AuthorizedOfficialFirstName: | LINDSAY | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 9145021450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OPEN DOOR FAMILY MEDICAL CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MBA FACMPE | ||||||||
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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) |
ID Information
| ID | Type | State | Issuer | Description | 03003587 | 05 | NY | MEDICAID |