Provider Demographics
NPI:1114137403
Name:COMMUNITY HEALTH CENTER OF RICHMOND, INC
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTER OF RICHMOND, INC
Other - Org Name:RICHMOND COMMUNITY SUPPORT ORGANIZATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF PATIENT FINANCIAL SERVI
Authorized Official - Prefix:
Authorized Official - First Name:LUCIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-924-2254
Mailing Address - Street 1:235 PORT RICHMOND AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1701
Mailing Address - Country:US
Mailing Address - Phone:718-924-2254
Mailing Address - Fax:718-442-0189
Practice Address - Street 1:235 PORT RICHMOND AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1701
Practice Address - Country:US
Practice Address - Phone:718-876-1732
Practice Address - Fax:718-442-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2903588261QF0400X
NY7004210R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7004210ROtherOPERATING CERTIFICATE #
NY2903588Medicaid
NY33-1988Medicare UPIN
NY331988Medicare Oscar/Certification
NYA100001122Medicare PIN