Basic Information
Provider Information | |||||||||
NPI: | 1699850669 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREATER HARLEM NURSING HOME AND REHABILITATION CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GREATER HARLEM NURSING HOME CO., INC. | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30 WEST 138TH STREET | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100371710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2126907400 | ||||||||
FaxNumber: | 2129261799 | ||||||||
Practice Location | |||||||||
Address1: | 30 WEST 138TH STREET | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100371710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2126907400 | ||||||||
FaxNumber: | 2129261799 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2006 | ||||||||
LastUpdateDate: | 04/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FORISTALL | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/CEO | ||||||||
AuthorizedOfficialTelephone: | 2126907400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 7002341N | NY | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 00309311 | 05 | NY |   | MEDICAID | 7002341N | 01 | NY | NURSING HOME OPERATING LC | OTHER | 9637 | 01 | NY | EMPIRE BCBS | OTHER |