Provider Demographics
NPI:1679933766
Name:NYS OMH SOUTH BEACH P.C.
Entity Type:Organization
Organization Name:NYS OMH SOUTH BEACH P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TEAM LEADER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEINBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-256-8818
Mailing Address - Street 1:777 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3409
Mailing Address - Country:US
Mailing Address - Phone:718-667-2300
Mailing Address - Fax:
Practice Address - Street 1:8620 18TH AVE
Practice Address - Street 2:BROOKLYN
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-3702
Practice Address - Country:US
Practice Address - Phone:718-256-8818
Practice Address - Fax:718-234-2314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00769306Medicaid