MEDICARE: STATE OF NEW YORK

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	00235626	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	:	1710027123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF NEW YORK

Provider Business Mailing Address
First Line	:	44 HOLLAND AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12229-0001
Country	:	US
Telephone Number	:	518-402-4333
Fax Number	:

Provider Business Practice Location Address
First Line	:	980 ELTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11208-5418
Country	:	US
Telephone Number	:	518-402-4333
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CENTRAL OPERATIONS
Name	:	KARLA SMITH
Credential	:
Telephone Number	:	518-402-4333

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	06/26/2008

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Directions to “STATE OF NEW YORK ” Practice Location

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