Provider Demographics
NPI:1750469912
Name:STATE OF NEW YORK COMPTROLLERS OFFICE
Entity Type:Organization
Organization Name:STATE OF NEW YORK COMPTROLLERS OFFICE
Other - Org Name:IBR GEORGE A JERVIS CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF CENTRAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-402-4333
Mailing Address - Street 1:44 HOLLAND AVENUE
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:518-473-1874
Practice Address - Street 1:1050 FOREST HILL RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6356
Practice Address - Country:US
Practice Address - Phone:718-494-5151
Practice Address - Fax:718-494-2258
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW YORK COMPTROLLERS OFFICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-02
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224141261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00869952Medicaid
NY224141OtherOMRDD OPERATING CERT #
NYA100018662Medicare PIN