Basic Information
| Provider Information | |||||||||
| NPI: | 1922004282 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEWITT REHABILITATION AND NURSING CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UPPER EAST SIDE REHABILITATION AND NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 211 E 79TH STREET | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100750891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128791600 | ||||||||
| FaxNumber: | 2128794594 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 EAST 79TH STREET | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100750819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128791600 | ||||||||
| FaxNumber: | 2128794594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 03/28/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEROSA | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2128791600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 7002374N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00310421 | 05 | NY | MEDICAID |