Basic Information
| Provider Information | |||||||||
| NPI: | 1972913473 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH PROJECT INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CALLEN-LORDE THEA SPYER CENTER FOR INTEGRATED HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 W 17TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100115325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122717200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 230 W 17TH SREET | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100115325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122717200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2014 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 2122717269 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 04101204 | 05 | NY | MEDICAID |