MEDICARE: PSC COMMUNITY SUPPORT SERVICES, INC.

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	302F00000X	Exclusive Provider Organization	1997L001	NY

General Provider Information

NPI Number	:	1871977009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSC COMMUNITY SUPPORT SERVICES, INC.

Provider Business Mailing Address
First Line	:	5102 21ST ST
Second Line	:	FOURTH FLOOR - 4-A
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5357
Country	:	US
Telephone Number	:	718-349-1905
Fax Number	:	718-349-0908

Provider Business Practice Location Address
First Line	:	5102 21ST ST
Second Line	:	FOURTH FLOOR - 4-A
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5357
Country	:	US
Telephone Number	:	718-349-1905
Fax Number	:	718-349-0908

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. CHRISTOPHER H. OLECHOWSKI
Credential	:
Telephone Number	:	718-349-1905

Provider Enumeration Date	:	07/17/2015
Last Update Date	:	01/28/2016

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