Provider Demographics
NPI:1225414329
Name:RICHMOND UNIVERSITY MEDICAL CENTER ADOLESCENT PROGRAM
Entity Type:Organization
Organization Name:RICHMOND UNIVERSITY MEDICAL CENTER ADOLESCENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AVP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:REN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-818-1380
Mailing Address - Street 1:669 CASTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2028
Mailing Address - Country:US
Mailing Address - Phone:718-442-2225
Mailing Address - Fax:718-442-2289
Practice Address - Street 1:669 CASTLETON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2028
Practice Address - Country:US
Practice Address - Phone:718-442-2225
Practice Address - Fax:718-442-2289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7749004A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00248820Medicaid
NY00248820Medicaid