Provider Demographics
NPI:1366526105
Name:RE BLAISDELL ADDICTION TREATMENT CENTER
Entity type:Organization
Organization Name:RE BLAISDELL ADDICTION TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOC COMMISIONER DIV OF FINANCIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-457-5312
Mailing Address - Street 1:BOX 140
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:NY
Mailing Address - Zip Code:10962-1129
Mailing Address - Country:US
Mailing Address - Phone:845-359-8500
Mailing Address - Fax:845-680-5510
Practice Address - Street 1:140 OLD ORANGEBURG RD
Practice Address - Street 2:BUILDING 57
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-1157
Practice Address - Country:US
Practice Address - Phone:845-359-8500
Practice Address - Fax:845-680-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01432333Medicaid