MEDICARE: NYSARC INC NYC CHAPTER

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	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61980504	OTHER	NY	NYS OMRDD

General Provider Information

NPI Number	:	1396065058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NYSARC INC NYC CHAPTER

Provider Business Mailing Address
First Line	:	83 MAIDEN LN
Second Line	:	8FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10038-4812
Country	:	US
Telephone Number	:	212-780-4459
Fax Number	:	212-777-4277

Provider Business Practice Location Address
First Line	:	126 E 126TH ST
Second Line	:	APT 5B
City	:	NEW YORK
State	:	NY
Zip	:	10035-1702
Country	:	US
Telephone Number	:	212-780-2538
Fax Number	:

Authorized Official
Title or Position	:	ASSOCIATE EXECUTIVE DIRECTOR
Name	:	ROBERT C GUNDERSON
Credential	:
Telephone Number	:	212-780-2665

Provider Enumeration Date	:	06/04/2010
Last Update Date	:	06/04/2010

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Directions to “NYSARC INC NYC CHAPTER ” Practice Location

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