1750469912 NPI number — STATE OF NEW YORK COMPTROLLERS OFFICE

Table of content: (NPI 1750469912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750469912 NPI number — STATE OF NEW YORK COMPTROLLERS OFFICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF NEW YORK COMPTROLLERS OFFICE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
IBR GEORGE A JERVIS CLINIC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750469912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 HOLLAND AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12229-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-402-4333
Provider Business Mailing Address Fax Number:
518-473-1874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 FOREST HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10314-6356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-494-5151
Provider Business Practice Location Address Fax Number:
718-494-2258
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JEFFERSON
Authorized Official First Name:
EARL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CENTRAL OPERATIONS
Authorized Official Telephone Number:
518-402-4333

Provider Taxonomy Codes

  • Taxonomy code: 261QD1600X , with the licence number:  224141 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00869952 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 224141 . This is a "OMRDD OPERATING CERT #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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