Provider Demographics
NPI:1316983430
Name:NYSARC INC PUTNAM COUNTY CHAPTER
Entity type:Organization
Organization Name:NYSARC INC PUTNAM COUNTY CHAPTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:DIB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-338-1234
Mailing Address - Street 1:575 DREWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-3736
Mailing Address - Country:US
Mailing Address - Phone:845-225-5650
Mailing Address - Fax:845-225-0758
Practice Address - Street 1:1938 RT. 6
Practice Address - Street 2:PARC CENTER
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512
Practice Address - Country:US
Practice Address - Phone:845-225-5650
Practice Address - Fax:845-228-0758
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUTNAM COUNTY CHAPTER NYSARC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-20
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7024300261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02698199Medicaid
NYW05251Medicare PIN