Provider Demographics
NPI:1487868162
Name:MONSIGNOR FITZPATRICK SN PAVILION
Entity type:Organization
Organization Name:MONSIGNOR FITZPATRICK SN PAVILION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-558-9696
Mailing Address - Street 1:15211 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3730
Mailing Address - Country:US
Mailing Address - Phone:718-558-9696
Mailing Address - Fax:718-558-2476
Practice Address - Street 1:15211 89TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3730
Practice Address - Country:US
Practice Address - Phone:718-558-9696
Practice Address - Fax:718-558-2476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009683313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY335689OtherHIP
NY009683OtherBLUE CROSS BLUE SHIELD
NY01044260Medicaid
NY169835OtherELDER PLANE
NY01044260Medicaid