MEDICARE: ICL ACT TEAM BUSHWICK

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	251S00000X	Community/Behavioral Health Agency
2	251B00000X	Case Management Agency	7720470A	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215184684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICL ACT TEAM BUSHWICK

Provider Business Mailing Address
First Line	:	40 RECTOR ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10006-1705
Country	:	US
Telephone Number	:	212-385-3030
Fax Number	:	212-385-2380

Provider Business Practice Location Address
First Line	:	2384 ATLANTIC AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11233-3402
Country	:	US
Telephone Number	:	212-385-3030
Fax Number	:	212-385-2380

Authorized Official
Title or Position	:	C F O
Name	:	MR. DEWEY HOWARD
Credential	:
Telephone Number	:	212-385-3030

Provider Enumeration Date	:	08/27/2008
Last Update Date	:	04/29/2010

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Directions to “ICL ACT TEAM BUSHWICK ” Practice Location

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