Provider Demographics
NPI:1649254806
Name:AMERIGROUP NEW YORK, LLC
Entity type:Organization
Organization Name:AMERIGROUP NEW YORK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAYTAIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-563-5570
Mailing Address - Street 1:360 W 31ST ST
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-2727
Mailing Address - Country:US
Mailing Address - Phone:212-563-5570
Mailing Address - Fax:212-563-5975
Practice Address - Street 1:360 W 31ST ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2727
Practice Address - Country:US
Practice Address - Phone:212-563-5570
Practice Address - Fax:212-563-5975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04-008302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01617894Medicaid
NY04-008OtherDOH HMO NUMBER
NY02644562OtherMLTC PROVIDER ID