Provider Demographics
NPI:1104831700
Name:MOTT HAVEN PHCY AND SURGICALS
Entity Type:Organization
Organization Name:MOTT HAVEN PHCY AND SURGICALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:AMIT
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-292-9144
Mailing Address - Street 1:400 E 141ST ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454
Mailing Address - Country:US
Mailing Address - Phone:718-292-9144
Mailing Address - Fax:718-292-9145
Practice Address - Street 1:400 EAST 141 STREET
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454
Practice Address - Country:US
Practice Address - Phone:718-292-9144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3349811OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY5599670001Medicare NSC