Provider Demographics
NPI: | 1700824372 |
---|---|
Name: | WYCKOFF HEIGHTS MEDICAL SERVICES PC |
Entity Type: | Organization |
Organization Name: | WYCKOFF HEIGHTS MEDICAL SERVICES PC |
Other - Org Name: | WYCKOFF ANESTHESIA MEDICAL SERVICES PC |
Other - Org Type: | Former Legal Business Name |
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: | |
Practice Address - Street 1: | 374 STOCKHOLM ST |
Practice Address - Street 2: | |
Practice Address - City: | BROOKLYN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11237 |
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: | 2006-06-03 |
Last Update Date: | 2019-04-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
No | 2082S0105X | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | Group - Multi-Specialty |
No | 2086S0120X | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | Group - Multi-Specialty |
No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 03299167 | Medicaid | |
NY | 03299167 | Medicaid |