Basic Information
| Provider Information | |||||||||
| NPI: | 1992997746 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINGSBORO PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 HOLLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122290001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 681 CLARKSON AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182217700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | PUCCIO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5184730795 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
ID Information
| ID | Type | State | Issuer | Description | 02890893 | 05 | NY | MEDICAID |