Provider Demographics
NPI:1639236672
Name:ST. LUKES- ROOSEVELT HOSPITAL CENTER
Entity Type:Organization
Organization Name:ST. LUKES- ROOSEVELT HOSPITAL CENTER
Other - Org Name:WESTCARE MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-308-1112
Mailing Address - Street 1:PO BOX 95000-2388
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2388
Mailing Address - Country:US
Mailing Address - Phone:212-308-1112
Mailing Address - Fax:212-308-1616
Practice Address - Street 1:2 W 86TH ST
Practice Address - Street 2:SUITE 3B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3666
Practice Address - Country:US
Practice Address - Phone:212-787-1788
Practice Address - Fax:212-787-1606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW2L471Medicare PIN