Provider Demographics
NPI:1184844870
Name:SOUTH ELLIOT SOUTH PORTLAND MEDICAL COMPREHENSIVE MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTH ELLIOT SOUTH PORTLAND MEDICAL COMPREHENSIVE MEDICAL CENTER
Other - Org Name:CAMILLE PHILIPPE
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILIPPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PC
Authorized Official - Phone:718-858-5088
Mailing Address - Street 1:GPO 27007
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-7007
Mailing Address - Country:US
Mailing Address - Phone:718-858-5088
Mailing Address - Fax:718-858-5278
Practice Address - Street 1:739 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1560
Practice Address - Country:US
Practice Address - Phone:718-858-5088
Practice Address - Fax:718-858-5278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0102306OtherUNITED HEALTHCARE
NY209917OtherWELLCARE
NY5C4093OtherHEALTHNET
NY5038C1OtherEMPIRE BCBS
NY00924438Medicaid
NY50013OtherVYTRA
NY10201320OtherAMERIGROUP
NY147143OtherHIP
NY650251OtherCIGNA
NYBKX033703OtherAMERICHOICE
NYP2664504OtherOXFORD
NY72468OtherGHI-HMO
NY5998068OtherGHI
NY147143C17OtherHEALTHFIRST
NY170899OtherELDERPLAN
NY2835366OtherAETNA
NY00924438Medicaid