Basic Information
| Provider Information | |||||||||
| NPI: | 1366716680 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLIAM F RYAN COMMUNITY HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WEST END INTERGENERATIONAL RESIDENCE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 483 W END AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100244340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127491820 | ||||||||
| FaxNumber: | 2129328323 | ||||||||
| Practice Location | |||||||||
| Address1: | 483 W END AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100244340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127491820 | ||||||||
| FaxNumber: | 2129328323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2012 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCINDOE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2123167906 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WILLIAM F RYAN COMMUNITY HEALTH CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 7002243R | NY | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 02999264 | 05 | NY | MEDICAID |