Provider Demographics
NPI:1841531795
Name:FPA HOSPITAL BASED
Entity type:Organization
Organization Name:FPA HOSPITAL BASED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, CBO DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MACNEILL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:212-241-6228
Mailing Address - Street 1:1468 MADISON AVE
Mailing Address - Street 2:ANNENBERG 03-08
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6508
Mailing Address - Country:US
Mailing Address - Phone:212-241-6064
Mailing Address - Fax:212-241-7832
Practice Address - Street 1:1468 MADISON AVE
Practice Address - Street 2:ANNENBERG 03-08
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6508
Practice Address - Country:US
Practice Address - Phone:212-731-7772
Practice Address - Fax:212-534-7491
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FPA HOSPITAL BASED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-01
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCLIA 33D1051889207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100113093Medicare PIN