Basic Information
| Provider Information | |||||||||
| NPI: | 1689715229 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF NEW YORK COMPTROLLERS OFFICE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CENTRAL NY DDSO - ROME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 HOLLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122290001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184024333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134402129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153396536 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 01/06/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JEFFERSON | ||||||||
| AuthorizedOfficialFirstName: | EARL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CENTRAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5184024333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF NEW YORK COMPTROLLERS OFFICE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | 00273840 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 01552363 | 05 | NY | MEDICAID |