Provider Demographics
NPI:1164586723
Name:5TH AVENUE PODIATRY, PC
Entity Type:Organization
Organization Name:5TH AVENUE PODIATRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMICHINO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:212-768-7999
Mailing Address - Street 1:36 W 44TH ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-8102
Mailing Address - Country:US
Mailing Address - Phone:212-768-7999
Mailing Address - Fax:212-398-8356
Practice Address - Street 1:36 W 44TH ST
Practice Address - Street 2:SUITE 401
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-8102
Practice Address - Country:US
Practice Address - Phone:212-768-7999
Practice Address - Fax:212-398-8356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004656213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0020595OtherGHI
4450726OtherAETNA
792279003OtherUNITED HEALTHCARE
P94591OtherEMPIRE BLUE CROSS BLUE SH
2C2743OtherHEALTHNET
P1537389OtherOXFORD
P1537389OtherOXFORD
NYP51092Medicare PIN
792279003OtherUNITED HEALTHCARE