Provider Demographics
NPI:1235112574
Name:INTREPID OF NEW YORK INC
Entity Type:Organization
Organization Name:INTREPID OF NEW YORK INC
Other - Org Name:INTREPID USA HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3750
Mailing Address - Street 1:4055 VALLEY VIEW LN
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5074
Mailing Address - Country:US
Mailing Address - Phone:214-445-3750
Mailing Address - Fax:214-445-3902
Practice Address - Street 1:3939 MERRICK RD
Practice Address - Street 2:FL2
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-2823
Practice Address - Country:US
Practice Address - Phone:516-781-7777
Practice Address - Fax:516-781-3252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1067L001251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02517095Medicaid