Provider Demographics
NPI:1215976113
Name:FEGS FAR ROCKAWAY MNTL HLTH
Entity type:Organization
Organization Name:FEGS FAR ROCKAWAY MNTL HLTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WAIZER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:212-366-8024
Mailing Address - Street 1:315 HUDSON ST
Mailing Address - Street 2:9TH FL.
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-1009
Mailing Address - Country:US
Mailing Address - Phone:212-366-8007
Mailing Address - Fax:212-366-8069
Practice Address - Street 1:1600 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4008
Practice Address - Country:US
Practice Address - Phone:718-327-1600
Practice Address - Fax:718-868-4792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6287100A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00257805Medicaid
NY00722Medicare PIN