Provider Demographics
NPI:1881026987
Name:NEW YORK PREMIER IPA
Entity type:Organization
Organization Name:NEW YORK PREMIER IPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-748-2109
Mailing Address - Street 1:9201 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7065
Mailing Address - Country:US
Mailing Address - Phone:718-748-2109
Mailing Address - Fax:718-748-5696
Practice Address - Street 1:9201 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7065
Practice Address - Country:US
Practice Address - Phone:718-748-2109
Practice Address - Fax:718-748-5696
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW YORK NETWORK MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization