Basic Information
| Provider Information | |||||||||
| NPI: | 1912953035 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF NEW YORK OFFICE OF PAYROLL ADMINISTRATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | NYCDOHMH BUSHWICK DISTRICT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42-09 28TH STREET CN-48 | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111014132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3473966234 | ||||||||
| FaxNumber: | 3473966366 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 CENTRAL AVE NYCDOHMH BUSHWICK DHC | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112214501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185734886 | ||||||||
| FaxNumber: | 7185734899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 05/03/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIRALDO | ||||||||
| AuthorizedOfficialFirstName: | MARITZA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3473966234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 7002112R13UT | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 00247585 | 05 | NY | MEDICAID |