Basic Information
| Provider Information | |||||||||
| NPI: | 1790713766 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF NEW YORK OFFICE OF PAYROLL ADMINISTRATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NEW YORK CITY DEPARTMENT OF HEALTH & MENTAL HYGIENE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 42-09 28TH STREET | ||||||||
| Address2: | CN-48 | ||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111014132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3473966234 | ||||||||
| FaxNumber: | 3473968961 | ||||||||
| Practice Location | |||||||||
| Address1: | 6710 ROCKAWAY BEACH BLVD | ||||||||
| Address2: | NYCDOHMH FAR ROCKAWAY HEALTH CENTER | ||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184742100 | ||||||||
| FaxNumber: | 7189452596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIRALDO | ||||||||
| AuthorizedOfficialFirstName: | MARITZA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3473966234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 7002112R1654 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 00247549 | 05 | NY | MEDICAID |