Provider Demographics
NPI:1104872506
Name:NYCDOHMH MOTTHYN CONNECT CMCM
Entity type:Organization
Organization Name:NYCDOHMH MOTTHYN CONNECT CMCM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MGR 3D PARTY REVENUE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SMOOK
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:212-442-5468
Mailing Address - Street 1:125 WORTH STREET
Mailing Address - Street 2:NYCDOHMH DIV OF DISEASE CONTROL RM 901 BOX 22
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-4006
Mailing Address - Country:US
Mailing Address - Phone:212-442-8468
Mailing Address - Fax:212-442-8452
Practice Address - Street 1:1309 FULTON AVENUE
Practice Address - Street 2:NYCDOHMH MOTT HAVEN CONNECT CMCM
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-2403
Practice Address - Country:US
Practice Address - Phone:718-367-2450
Practice Address - Fax:718-367-5112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01234413026261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01234413Medicaid