Basic Information
| Provider Information | |||||||||
| NPI: | 1831307628 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOSEPH P. ADDABBO FAMILY HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6200 BEACH CHANNEL DRIVE | ||||||||
| Address2: | |||||||||
| City: | ARVERNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189457150 | ||||||||
| FaxNumber: | 7189457150 | ||||||||
| Practice Location | |||||||||
| Address1: | 6200 BEACH CHANNEL DRIVE | ||||||||
| Address2: | |||||||||
| City: | ARVERNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189457150 | ||||||||
| FaxNumber: | 7189452596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 03/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | FLIEGEL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACTING CEO | ||||||||
| AuthorizedOfficialTelephone: | 7189457150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 071513 | NY | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 00990152 | 05 | NY | MEDICAID | 0990152 | 05 | NY | MEDICAID |