Basic Information
Provider Information | |||||||||
NPI: | 1841536554 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | METRO COMMUNITY HEALTH CENTERS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40 RECTOR ST FL 15 | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100061722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2129475770 | ||||||||
FaxNumber: | 2123561348 | ||||||||
Practice Location | |||||||||
Address1: | 979 CROSS BRONX EXPY | ||||||||
Address2: | SERVICE ROAD NORTH | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 104604885 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186657565 | ||||||||
FaxNumber: | 7183285881 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2012 | ||||||||
LastUpdateDate: | 06/28/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WONG | ||||||||
AuthorizedOfficialFirstName: | FRED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2129475770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 571005 | 01 | NY | CMS CERTIFICATION | OTHER | 04195942 | 05 | NY |   | MEDICAID |