Provider Demographics
NPI:1457306680
Name:TOTAL HEALTH AT LICH
Entity Type:Organization
Organization Name:TOTAL HEALTH AT LICH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-780-2777
Mailing Address - Street 1:350 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-6001
Mailing Address - Country:US
Mailing Address - Phone:516-569-0696
Mailing Address - Fax:516-569-3677
Practice Address - Street 1:350 HENRY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6001
Practice Address - Country:US
Practice Address - Phone:516-569-0696
Practice Address - Fax:516-569-3677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEQ371Medicare PIN