Provider Demographics
NPI:1235537655
Name:WHITNEY M. YOUNG JR. HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:WHITNEY M. YOUNG JR. HEALTH CENTER, INC.
Other - Org Name:MOBILE VAN UNIT
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHIPPEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-465-4771
Mailing Address - Street 1:320 SEVENTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182
Mailing Address - Country:US
Mailing Address - Phone:518-465-4771
Mailing Address - Fax:518-320-3022
Practice Address - Street 1:920 LARK DR
Practice Address - Street 2:WHITNEY M. YOUNG JR. HEALTH CENTER - MOBILE VAN
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207-1300
Practice Address - Country:US
Practice Address - Phone:518-465-4771
Practice Address - Fax:518-320-3022
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITNEY M. YOUNG JR. HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0101205R261QC1500X, 261QF0400X
NY010120R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00473565Medicaid