Basic Information
Provider Information | |||||||||
NPI: | 1669746905 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WILLIAM F RYAN COMMUNITY HEALTH CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE BRIDGE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 248 W 108TH ST | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100252956 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127491820 | ||||||||
FaxNumber: | 2129328323 | ||||||||
Practice Location | |||||||||
Address1: | 248 W 108TH ST | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100252956 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127491820 | ||||||||
FaxNumber: | 2129328323 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2012 | ||||||||
LastUpdateDate: | 11/19/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCINDOE | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 2123167906 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WILLIAM F RYAN COMMUMNITY HEALTH CENTER INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X |   |   | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | 02999264 | 05 | NY |   | MEDICAID |