Basic Information
| Provider Information | |||||||||
| NPI: | 1679933766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYS OMH SOUTH BEACH P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 SEAVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103053409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186672300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8620 18TH AVE | ||||||||
| Address2: | BROOKLYN | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112143702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182568818 | ||||||||
| FaxNumber: | 7182342314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | KLEINBAUM | ||||||||
| AuthorizedOfficialFirstName: | ALFRED | ||||||||
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| AuthorizedOfficialTitleorPosition: | TEAM LEADER | ||||||||
| AuthorizedOfficialTelephone: | 7182568818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | NY | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | 00769306 | 05 | NY | MEDICAID |