Provider Demographics
NPI:1275673287
Name:STATE OF NEW YORK
Entity Type:Organization
Organization Name:STATE OF NEW YORK
Other - Org Name:STATEN ISLAND DDSO 24A EXEC W
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF CENTRAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-402-4333
Mailing Address - Street 1:44 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12229-0001
Mailing Address - Country:US
Mailing Address - Phone:518-402-4333
Mailing Address - Fax:
Practice Address - Street 1:24 O EXECUTIVE WAY
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:518-402-4333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW YORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-07
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00276639315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01032315Medicaid