Provider Demographics
NPI:1164679395
Name:THIRD AVENUE GASTROENTEROLOGY, P.C.
Entity Type:Organization
Organization Name:THIRD AVENUE GASTROENTEROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:SUNGWON
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-794-0240
Mailing Address - Street 1:1317 3RD AVE
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-2995
Mailing Address - Country:US
Mailing Address - Phone:212-794-0240
Mailing Address - Fax:
Practice Address - Street 1:1317 3RD AVE
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2995
Practice Address - Country:US
Practice Address - Phone:212-794-0240
Practice Address - Fax:212-570-2038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190910261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy