Provider Demographics
NPI:1174014971
Name:GRAMERCY MEDICAL PC
Entity Type:Organization
Organization Name:GRAMERCY MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-270-7648
Mailing Address - Street 1:3120 54TH ST STE L2
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-1549
Mailing Address - Country:US
Mailing Address - Phone:718-476-5859
Mailing Address - Fax:
Practice Address - Street 1:3120 54TH ST STE L2
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-1549
Practice Address - Country:US
Practice Address - Phone:718-476-5859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1821120833OtherINDIVIDUAL NPI