Healthcare Provider Details

I. General information

NPI: 1699817577
Provider Name (Legal Business Name): CREEDMOOR PSYCHIATRIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 ROSLYN WEST SHORE RD,
PORT WASHINGTON NY
11050
US

IV. Provider business mailing address

8045 WINCHESTER BLVD
QUEENS VILLAGE NY
11427-2193
US

V. Phone/Fax

Practice location:
  • Phone: 516-883-4757
  • Fax:
Mailing address:
  • Phone: 718-464-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number126421
License Number StateNY

VIII. Authorized Official

Name: DR. ALAN DINER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 718-264-4046