Basic Information
| Provider Information | |||||||||
| NPI: | 1265478432 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEWYORK-PRESBYTERIAN-QUEENS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | 8TH FLOOR HOSPITAL DIALYSIS UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5645 MAIN ST | ||||||||
| Address2: | 8TH FLOOR HOSPITAL DIALYSIS UNIT | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186701231 | ||||||||
| FaxNumber: | 7186617942 | ||||||||
| Practice Location | |||||||||
| Address1: | 5645 MAIN ST | ||||||||
| Address2: | EIGHTH FLOOR DIALYSIS UNIT | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186701231 | ||||||||
| FaxNumber: | 7186617942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANTOS | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | R.F. | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP, CFO AND TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2127467905 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NYP COMMUNITY PROGRAMS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 7003010H PFI 1637 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 332311 | 01 | NY | MEDICARE PTAN | OTHER | 02998983 | 05 | NY | MEDICAID | 00244133 | 05 | NY | MEDICAID |