Provider Demographics
NPI:1124232939
Name:CORINTHIAN MEDICAL IPA
Entity Type:Organization
Organization Name:CORINTHIAN MEDICAL IPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:MODESTO
Authorized Official - Last Name:TALLAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-740-8294
Mailing Address - Street 1:481 FORT WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-4654
Mailing Address - Country:US
Mailing Address - Phone:212-740-8294
Mailing Address - Fax:212-740-8289
Practice Address - Street 1:481 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-4654
Practice Address - Country:US
Practice Address - Phone:212-740-8294
Practice Address - Fax:212-740-8289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherTAX IDENTIFCATION