Provider Demographics
NPI:1417026600
Name:ST. BARNABAS OG GYN P.C.
Entity type:Organization
Organization Name:ST. BARNABAS OG GYN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSE MIDWIFE
Authorized Official - Prefix:MISS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:718-960-9000
Mailing Address - Street 1:4422 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2545
Mailing Address - Country:US
Mailing Address - Phone:718-960-9000
Mailing Address - Fax:718-960-9414
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-9000
Practice Address - Fax:718-960-9414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000486367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01779886Medicaid