Provider Demographics
NPI:1053588988
Name:UNDER 21
Entity type:Organization
Organization Name:UNDER 21
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:212-613-0300
Mailing Address - Street 1:460 W 41ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036
Mailing Address - Country:US
Mailing Address - Phone:212-613-0300
Mailing Address - Fax:212-268-2832
Practice Address - Street 1:460 W 41ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036
Practice Address - Country:US
Practice Address - Phone:212-613-0300
Practice Address - Fax:212-268-2832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00733826Medicaid