Provider Demographics
NPI:1013360528
Name:WILLIAM F RYAN COMMUNITY HEALTH CENTER INC
Entity Type:Organization
Organization Name:WILLIAM F RYAN COMMUNITY HEALTH CENTER INC
Other - Org Name:RYAN FREDERICK DOUGLASS COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-222-5221
Mailing Address - Street 1:2381 FREDERICK DOUGLASS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-1822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2381 FREDERICK DOUGLASS BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-1822
Practice Address - Country:US
Practice Address - Phone:212-749-1820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM F RYAN COMMUNITY HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-20
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7002243R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04633116Medicaid
NY04633116Medicaid