Basic Information
Provider Information | |||||||||
NPI: | 1770962391 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WYCKOFF PEDIATRIC CARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1411 MYRTLE AVENUE | ||||||||
Address2: | WYCKOFF PEDIATRIC CARE CENTER | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 11237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189074301 | ||||||||
FaxNumber: | 7189191309 | ||||||||
Practice Location | |||||||||
Address1: | 374 STOCKHOLM STREET | ||||||||
Address2: | WYCKOFF HEIGHTS MEDICAL CENTER - FACULTY PRACTICE | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 11237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189637272 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/28/2015 | ||||||||
LastUpdateDate: | 05/28/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VUTRANO | ||||||||
AuthorizedOfficialFirstName: | FRANK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7189636702 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WYCKOFF PROFESSIONAL MEDICAL SERVICES PC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 03722025 | 05 | NY |   | MEDICAID |