Provider Demographics
NPI:1740520949
Name:AGEWELL NEW YORK, LLC
Entity type:Organization
Organization Name:AGEWELL NEW YORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUONOCORE-RUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-289-2669
Mailing Address - Street 1:27111 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1436
Mailing Address - Country:US
Mailing Address - Phone:866-586-8044
Mailing Address - Fax:855-366-4110
Practice Address - Street 1:27111 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1436
Practice Address - Country:US
Practice Address - Phone:866-586-8044
Practice Address - Fax:855-366-4110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03481927Medicaid