Provider Demographics
NPI:1912100454
Name:ICD INTERNATIONAL CENTER FOR THE DISABLED
Entity Type:Organization
Organization Name:ICD INTERNATIONAL CENTER FOR THE DISABLED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:LES
Authorized Official - Middle Name:
Authorized Official - Last Name:HALPERT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:212-585-6009
Mailing Address - Street 1:340 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4019
Mailing Address - Country:US
Mailing Address - Phone:212-585-6000
Mailing Address - Fax:212-585-6262
Practice Address - Street 1:340 E 24TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4019
Practice Address - Country:US
Practice Address - Phone:212-585-6000
Practice Address - Fax:212-585-6262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6704100A261QM0801X
NY090110619261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3186529OtherGHI-BMP
NY00244413Medicaid
NY58P0081OtherNYPRESBY HEALTH PLAN
NY1054350OtherBEACON HEALTH STRATEGIES
NYA31902OtherPERFORMAX-MULTIPLAN
NYDB5292OtherRAILROAD RETIREMENT BOARD
NY040816000080OtherFIDELIS CARE NEW YORK
NY040816000080OtherFIDELIS CARE NEW YORK