Provider Demographics
NPI:1285680389
Name:NYCDOHMH HILLSIDE AVENUE HEALTH CENTER
Entity Type:Organization
Organization Name:NYCDOHMH HILLSIDE AVENUE HEALTH CENTER
Other - Org Name:NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE HILLSIDE AVENUE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE MANAGER THIRD PARTY
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SMOOK
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:212-442-8468
Mailing Address - Street 1:PO BOX 74
Mailing Address - Street 2:125 WORTH STREET RM 901
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4006
Mailing Address - Country:US
Mailing Address - Phone:212-442-8468
Mailing Address - Fax:212-442-8452
Practice Address - Street 1:164 21 HILLSIDE AVENUE
Practice Address - Street 2:NYCDOHMH HILLSIDE AVENUE HEALTH CENTER
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4140
Practice Address - Country:US
Practice Address - Phone:718-676-2259
Practice Address - Fax:718-262-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7002112R5621261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00247549Medicaid
NY00247549Medicaid