Provider Demographics
NPI:1699928341
Name:CREEDMOOR PSYCHIATRIC CENTER
Entity type:Organization
Organization Name:CREEDMOOR PSYCHIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:WANGECHI
Authorized Official - Last Name:MUGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-263-0078
Mailing Address - Street 1:7925 WINCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2128
Mailing Address - Country:US
Mailing Address - Phone:718-264-5030
Mailing Address - Fax:
Practice Address - Street 1:7925 WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2128
Practice Address - Country:US
Practice Address - Phone:718-264-5030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit