Provider Demographics
NPI:1245762780
Name:CITY MEDICAL OF UPPER EAST SIDE, PLLC
Entity Type:Organization
Organization Name:CITY MEDICAL OF UPPER EAST SIDE, PLLC
Other - Org Name:CITYMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:VICIOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-783-4600
Mailing Address - Street 1:1345 RXR PLZ
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:516-783-4600
Mailing Address - Fax:646-846-3283
Practice Address - Street 1:16221 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4909
Practice Address - Country:US
Practice Address - Phone:718-571-9116
Practice Address - Fax:718-571-9121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY MEDICAL OF UPPER EAST SIDE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care