Basic Information
Provider Information | |||||||||
NPI: | 1952718181 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUN RIVER HEALTH INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HRHCARE WYANDANCH | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5036 | ||||||||
Address2: |   | ||||||||
City: | WHITE PLAINS | ||||||||
State: | NY | ||||||||
PostalCode: | 106025036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9147348800 | ||||||||
FaxNumber: | 9147348786 | ||||||||
Practice Location | |||||||||
Address1: | 1556 STRAIGHT PATH | ||||||||
Address2: |   | ||||||||
City: | WYANDANCH | ||||||||
State: | NY | ||||||||
PostalCode: | 117983213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5162148020 | ||||||||
FaxNumber: | 5162148022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2014 | ||||||||
LastUpdateDate: | 03/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LIPTON | ||||||||
AuthorizedOfficialFirstName: | ADAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP INFO/PRACTICE MGMT SYSTEMS | ||||||||
AuthorizedOfficialTelephone: | 9143842375 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SUN RIVER HEALTH INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | N |   | Agencies | Case Management |   | 261QF0400X | 5901200R | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 00473038 | 05 | NY |   | MEDICAID |