Basic Information
| Provider Information | |||||||||
| NPI: | 1851571392 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROWNSVILLE COMMUNITY DEVELOPMENT CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BMS-ISIS @ BRISTOL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 BRISTOL ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112125540 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 259 BRISTOL ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112125540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183455000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2007 | ||||||||
| LastUpdateDate: | 01/22/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | HARVEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7183455000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROWNSVILLE COMMUNIT DEVELOPMENT CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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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 | 00723253 | 05 | NY | MEDICAID |