=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285680389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NYCDOHMH HILLSIDE AVENUE HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 164 21 HILLSIDE AVENUE NYCDOHMH HILLSIDE AVENUE HEALTH CENTER
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-4140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-676-2259
-----------------------------------------------------
Fax | 718-262-8885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 74 125 WORTH STREET RM 901
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10013-4006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-442-8468
-----------------------------------------------------
Fax | 212-442-8452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE MANAGER THIRD PARTY
-----------------------------------------------------
Name | MR. MICHAEL JAMES SMOOK
-----------------------------------------------------
Credential | MPA
-----------------------------------------------------
Telephone | 212-442-8468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | 7002112R5621
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------