Provider Demographics
NPI:1811240112
Name:WALL STREET PHYSICIAN PLLC
Entity Type:Organization
Organization Name:WALL STREET PHYSICIAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-784-0072
Mailing Address - Street 1:111 BROADWAY
Mailing Address - Street 2:SUITE 402
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006-1901
Mailing Address - Country:US
Mailing Address - Phone:212-784-0072
Mailing Address - Fax:212-784-0076
Practice Address - Street 1:111 BROADWAY
Practice Address - Street 2:SUITE 402
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-1901
Practice Address - Country:US
Practice Address - Phone:212-784-0072
Practice Address - Fax:212-784-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1676231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A61524Medicare UPIN