Provider Demographics
NPI:1962579235
Name:STATE OF NEW YORK
Entity type:Organization
Organization Name:STATE OF NEW YORK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LAB DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:C
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:718-494-5236
Mailing Address - Street 1:1050 FOREST HILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6356
Mailing Address - Country:US
Mailing Address - Phone:718-494-5345
Mailing Address - Fax:718-494-0694
Practice Address - Street 1:1050 FOREST HILL RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6356
Practice Address - Country:US
Practice Address - Phone:718-494-5345
Practice Address - Fax:718-494-0694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7097M040291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
33D0860102OtherCLIA
NY00782518Medicaid
NY7097M040OtherNYS LAB LICENSE
NY7097M040OtherNYS LAB LICENSE