Provider Demographics
NPI:1982186870
Name:INDEPENDENCE CARE SYSTEM, INC.
Entity Type:Organization
Organization Name:INDEPENDENCE CARE SYSTEM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, COMPLIANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GOGGIN-CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:646-653-6142
Mailing Address - Street 1:257 PARK AVE S
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-7304
Mailing Address - Country:US
Mailing Address - Phone:646-653-6142
Mailing Address - Fax:
Practice Address - Street 1:25 ELM PL FL 5
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5826
Practice Address - Country:US
Practice Address - Phone:212-584-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01865329Medicaid