Provider Demographics
NPI:1538479217
Name:JEROME L. SHUPACK, MD PC
Entity Type:Organization
Organization Name:JEROME L. SHUPACK, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:SHUPACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-263-7344
Mailing Address - Street 1:530 1ST AVE # 7F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-7344
Mailing Address - Fax:212-263-5991
Practice Address - Street 1:530 1ST AVE # 7F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-7344
Practice Address - Fax:212-263-5991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092742207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty