Basic Information
Provider Information
NPI: 1760631451
EntityType: 2
ReplacementNPI:  
OrganizationName: UCP ASSOC OF NYS
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: CEREBRAL PALSY ASSN OF NYS
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 330 W 34TH ST FL 15
Address2:  
City: NEW YORK
State: NY
PostalCode: 100012406
CountryCode: US
TelephoneNumber: 2129475770
FaxNumber: 2123561348
Practice Location
Address1: 801 CYPRESS ST
Address2:  
City: ROME
State: NY
PostalCode: 134402129
CountryCode: US
TelephoneNumber: 3157246907
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/17/2008
LastUpdateDate: 09/17/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MANDELKOW
AuthorizedOfficialFirstName: THOMAS
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: EXEC VICE PRES
AuthorizedOfficialTelephone: 2129475770
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QD1600X NYY Ambulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities

ID Information
IDTypeStateIssuerDescription
0094732405NY MEDICAID


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