MEDICARE: STATE OF NEW YORK COMPTROLLERS OFFICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1356286124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF NEW YORK COMPTROLLERS OFFICE

Provider Business Mailing Address
First Line	:	44 HOLLAND AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12208-3411
Country	:	US
Telephone Number	:	518-402-4333
Fax Number	:

Provider Business Practice Location Address
First Line	:	930 WILLOWBROOK RD BLDG 15L
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-4209
Country	:	US
Telephone Number	:	518-402-4333
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CENTRAL OPERATIONS
Name	:	EARL JEFFERSON
Credential	:
Telephone Number	:	518-402-4333

Provider Enumeration Date	:	04/20/2026
Last Update Date	:	04/20/2026

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