Healthcare Provider Details

I. General information

NPI: 1235537655
Provider Name (Legal Business Name): WHITNEY M. YOUNG JR. HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 LARK DR WHITNEY M. YOUNG JR. HEALTH CENTER - MOBILE VAN
ALBANY NY
12207-1300
US

IV. Provider business mailing address

320 SEVENTH AVENUE
TROY NY
12182
US

V. Phone/Fax

Practice location:
  • Phone: 518-465-4771
  • Fax: 518-320-3022
Mailing address:
  • Phone: 518-465-4771
  • Fax: 518-320-3022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number0101205R
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number0101205R
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number010120R
License Number StateNY

VIII. Authorized Official

Name: DAVID H SHIPPEE
Title or Position: CEO/PRESIDENT
Credential:
Phone: 518-465-4771