Provider Demographics
NPI:1083808877
Name:ANSELM, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:ANSELM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 EAST 17TH STREET
Mailing Address - Street 2:APARTMENT 27B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3681
Mailing Address - Country:US
Mailing Address - Phone:646-447-7468
Mailing Address - Fax:866-387-5760
Practice Address - Street 1:201 EAST 17TH STREET
Practice Address - Street 2:APARTMENT 27B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3681
Practice Address - Country:US
Practice Address - Phone:646-447-7468
Practice Address - Fax:866-387-5760
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1551711207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD91751Medicare UPIN