Basic Information
| Provider Information | |||||||||
| NPI: | 1982875183 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYU LUTHERAN MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 3RD AVE | ||||||||
| Address2: | LUTHERAN MEDICAL CENTER MANAGED CARE DEPARTMENT | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112203702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186307477 | ||||||||
| FaxNumber: | 7186307437 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 55TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112202559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186307133 | ||||||||
| FaxNumber: | 7186307437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2008 | ||||||||
| LastUpdateDate: | 05/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | DELLACERRA | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP MANAGED CARE & REVENUE COMPLIANC | ||||||||
| AuthorizedOfficialTelephone: | 7186307103 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | V.P. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 12263 | NY | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 01228720 | 05 | NY | MEDICAID |