Basic Information
| Provider Information | |||||||||
| NPI: | 1649334541 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CREEDMOOR PSYCHIATRIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 HOLLAND AVE | ||||||||
| Address2: | ATTN: SOFG/MEDICARE D | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122290000 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 5184864303 | ||||||||
| Practice Location | |||||||||
| Address1: | 8045 WINCHESTER BLVD | ||||||||
| Address2: | |||||||||
| City: | QUEENS VILLAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114272193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184647500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | GIARRUSSO | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
| AuthorizedOfficialMiddleName: | GAIL | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5184733598 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NYS OFFICE OF MENTAL HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336I0012X | NY | Y | Suppliers | Pharmacy | Institutional Pharmacy |
No ID Information.