Basic Information
| Provider Information | |||||||||
| NPI: | 1912436858 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTHCARE NETWORK, INC. | ||||||||
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| OtherOrganizationName: | PHOENIX SCHOOL BASED HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MADISON AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100101600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125452439 | ||||||||
| FaxNumber: | 6463120481 | ||||||||
| Practice Location | |||||||||
| Address1: | 504 W. 158TH STREET | ||||||||
| Address2: | 5TH FLOOR, ROOM 511 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100327202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175213130 | ||||||||
| FaxNumber: | 9175213108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2017 | ||||||||
| LastUpdateDate: | 06/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | WENGROFSKY | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 2125452439 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 7002119R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 00695941 | 05 | NY | MEDICAID |