Provider Demographics
NPI:1457831174
Name:PERFORMANCE MEDICAL PRAACTICE LLC
Entity Type:Organization
Organization Name:PERFORMANCE MEDICAL PRAACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-813-0535
Mailing Address - Street 1:160 E 56TH ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011
Mailing Address - Country:US
Mailing Address - Phone:646-866-6076
Mailing Address - Fax:917-281-7912
Practice Address - Street 1:160 E 56TH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:646-866-6076
Practice Address - Fax:917-261-7912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284515207QS0010X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty