Provider Demographics
NPI:1306224001
Name:57 WEST DERMATOLOGY LLC
Entity Type:Organization
Organization Name:57 WEST DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-297-2691
Mailing Address - Street 1:57 W 57TH ST
Mailing Address - Street 2:SUITE 1109
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2802
Mailing Address - Country:US
Mailing Address - Phone:516-297-2691
Mailing Address - Fax:
Practice Address - Street 1:57 W 57TH ST
Practice Address - Street 2:SUITE 1109
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2802
Practice Address - Country:US
Practice Address - Phone:516-297-2691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196509207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG14795Medicare UPIN
NYQ27626Medicare UPIN