Basic Information
| Provider Information | |||||||||
| NPI: | 1427125632 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SES OPERATING CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HARLEM EAST LIFE PLAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2367 -69 SECOND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100353108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128762300 | ||||||||
| FaxNumber: | 9174929202 | ||||||||
| Practice Location | |||||||||
| Address1: | 2367 -69 SECOND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100353108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128762300 | ||||||||
| FaxNumber: | 9174929202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 06/23/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEINER | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2128762300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 067AN1 | 01 | NY | EMPIRE BLUE CROSS BLUE SH | OTHER | 01979006 | 05 | NY | MEDICAID | 237162 | 01 | NY | HEALTHFIRST | OTHER |