Provider Demographics
NPI:1205111861
Name:NEW YORK STATE CATHOLIC HEALTH PLAN, INC.
Entity type:Organization
Organization Name:NEW YORK STATE CATHOLIC HEALTH PLAN, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-896-6500
Mailing Address - Street 1:9525 QUEENS BLVD
Mailing Address - Street 2:8TH FL
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4510
Mailing Address - Country:US
Mailing Address - Phone:718-896-6500
Mailing Address - Fax:718-896-2755
Practice Address - Street 1:9525 QUEENS BLVD
Practice Address - Street 2:8TH FL
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4510
Practice Address - Country:US
Practice Address - Phone:718-896-6500
Practice Address - Fax:718-896-2755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC-027194302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC-027194Medicaid