Provider Demographics
NPI: | 1417517012 |
---|---|
Name: | CITY MEDICAL OF UPPER EAST SIDE, PLLC |
Entity Type: | Organization |
Organization Name: | CITY MEDICAL OF UPPER EAST SIDE, PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | VP, CREDENTIALING/ENROLLMENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MARLENA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SIMPSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | CPMSM |
Authorized Official - Phone: | 516-453-0435 |
Mailing Address - Street 1: | 1345 RXR PLZ FL 13 |
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: | 516-453-0435 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1243 FULTON ST |
Practice Address - Street 2: | |
Practice Address - City: | BROOKLYN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11216-2004 |
Practice Address - Country: | US |
Practice Address - Phone: | 646-647-1257 |
Practice Address - Fax: | 646-647-1258 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | CITY MEDICAL OF UPPER EAST SIDE, PLLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2019-06-17 |
Last Update Date: | 2019-06-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |