Provider Demographics
NPI:1043483274
Name:GRAND CORNELL CARDIOLOGY PC
Entity Type:Organization
Organization Name:GRAND CORNELL CARDIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACC
Authorized Official - Phone:212-233-8813
Mailing Address - Street 1:217 GRAND ST FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4223
Mailing Address - Country:US
Mailing Address - Phone:212-233-8813
Mailing Address - Fax:212-267-3303
Practice Address - Street 1:217 GRAND ST FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4223
Practice Address - Country:US
Practice Address - Phone:212-233-8813
Practice Address - Fax:212-267-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173277174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03109868Medicaid
NY03109868Medicaid
NYWWR321Medicare PIN