Provider Demographics
NPI:1730559477
Name:HOSPITAL
Entity type:Organization
Organization Name:HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:PAULA
Authorized Official - Last Name:IPPOLITO-FATA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-329-1000
Mailing Address - Street 1:2466 ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-6004
Mailing Address - Country:US
Mailing Address - Phone:718-329-1000
Mailing Address - Fax:
Practice Address - Street 1:2466 ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-6004
Practice Address - Country:US
Practice Address - Phone:718-329-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0432151223G0001X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02259254Medicaid
NY043215OtherNEW YORK STATE EDUCATION DEPARTMENT LICENSE NUMBER