Provider Demographics
NPI: | 1659710796 |
---|---|
Name: | WYCKOFF PROFESSIONAL MEDICAL SERVICES, PC |
Entity Type: | Organization |
Organization Name: | WYCKOFF PROFESSIONAL MEDICAL SERVICES, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | VALI |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GACHE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 718-240-1795 |
Mailing Address - Street 1: | 374 STOCKHOLM ST |
Mailing Address - Street 2: | |
Mailing Address - City: | BROOKLYN |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11237-4006 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 718-963-6485 |
Mailing Address - Fax: | 718-963-6793 |
Practice Address - Street 1: | 374 STOCKHOLM ST |
Practice Address - Street 2: | |
Practice Address - City: | BROOKLYN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11237-4006 |
Practice Address - Country: | US |
Practice Address - Phone: | 718-963-6485 |
Practice Address - Fax: | 718-963-6793 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-06-21 |
Last Update Date: | 2019-04-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2080N0001X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 03722025 | Medicaid | |
NY | 03722025 | Medicaid |