Provider Demographics
NPI:1497894414
Name:NYFOUNDLING HOSPITAL AKA ST AGATHAS PELHAM MANOR ICF
Entity Type:Organization
Organization Name:NYFOUNDLING HOSPITAL AKA ST AGATHAS PELHAM MANOR ICF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:BACCAGLINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-886-4075
Mailing Address - Street 1:590 AVENUE OF THE AMERICAS
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011
Mailing Address - Country:US
Mailing Address - Phone:212-727-6977
Mailing Address - Fax:
Practice Address - Street 1:1 SHOREVIEW CIRCLE
Practice Address - Street 2:PELHAM MANOR
Practice Address - City:PELHAM MANOR
Practice Address - State:NY
Practice Address - Zip Code:10803
Practice Address - Country:US
Practice Address - Phone:212-633-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY07107440315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00518754Medicaid