1831696509 NPI number — BRIDGEPARK OPERATIONS, LLC

Table of content: (NPI 1831696509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831696509 NPI number — BRIDGEPARK OPERATIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGEPARK OPERATIONS, LLC
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:
AUTUMN LAKE HEALTHCARE AT BRIDGEPARK
Provider Other Organization Name Type Code:
3
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:
1831696509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14C 53RD ST STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11232-2644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-567-0400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4017 LIBERTY HEIGHTS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21207-7545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-567-0402
Provider Business Practice Location Address Fax Number:
718-567-0600
Provider Enumeration Date:
04/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
STERN
Authorized Official First Name:
SAM
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
718-567-0400

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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