Provider Demographics
NPI:1932499274
Name:URBAN HEALTH PLAN, INC.
Entity Type:Organization
Organization Name:URBAN HEALTH PLAN, INC.
Other - Org Name:KIPS BAYS BOYS AND GIRLS CLUB/CREST SMILE SHOPPE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP MEDICAL AFFAIRS/CMO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DELEON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-589-2440
Mailing Address - Street 1:1065 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-2417
Mailing Address - Country:US
Mailing Address - Phone:718-589-2440
Mailing Address - Fax:
Practice Address - Street 1:1930 RANDALL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2608
Practice Address - Country:US
Practice Address - Phone:718-893-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIPS BAYS BOYS AND GIRLS CLUB/CREST SMILE SHOPPE DENTAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02994952Medicaid
NY331885Medicare Oscar/Certification