Provider Demographics
NPI:1083069439
Name:FIFTH AVENUE MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:FIFTH AVENUE MEDICAL ASSOCIATES, LLC
Other - Org Name:BENY J. PRIMM MEDICAL GROUP, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:Y
Authorized Official - Last Name:JIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-898-2037
Mailing Address - Street 1:745 5TH AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10151-0099
Mailing Address - Country:US
Mailing Address - Phone:646-898-2037
Mailing Address - Fax:
Practice Address - Street 1:745 5TH AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10151-0099
Practice Address - Country:US
Practice Address - Phone:646-898-2037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101838261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02216131Medicaid