Provider Demographics
NPI:1316342603
Name:INDEPENDENCE CARE SYSTEM, INC.
Entity type:Organization
Organization Name:INDEPENDENCE CARE SYSTEM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:GOGGIN-CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-653-6142
Mailing Address - Street 1:25 ELM PL FL 5
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5826
Mailing Address - Country:US
Mailing Address - Phone:877-427-2525
Mailing Address - Fax:212-584-2555
Practice Address - Street 1:25 ELM PL FL 5
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5826
Practice Address - Country:US
Practice Address - Phone:877-427-2525
Practice Address - Fax:212-584-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-29
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05451574Medicaid