Healthcare Provider Details

I. General information

NPI: 1285680389
Provider Name (Legal Business Name): NYCDOHMH HILLSIDE AVENUE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 21 HILLSIDE AVENUE NYCDOHMH HILLSIDE AVENUE HEALTH CENTER
JAMAICA NY
11432-4140
US

IV. Provider business mailing address

PO BOX 74 125 WORTH STREET RM 901
NEW YORK NY
10013-4006
US

V. Phone/Fax

Practice location:
  • Phone: 718-676-2259
  • Fax: 718-262-8885
Mailing address:
  • Phone: 212-442-8468
  • Fax: 212-442-8452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number7002112R5621
License Number StateNY

VIII. Authorized Official

Name: MR. MICHAEL JAMES SMOOK
Title or Position: ADMINISTRATIVE MANAGER THIRD PARTY
Credential: MPA
Phone: 212-442-8468