Provider Demographics
NPI:1831468966
Name:SLRHC FACULITY PRACTICE
Entity Type:Organization
Organization Name:SLRHC FACULITY PRACTICE
Other - Org Name:SLRHC FPP RICHARD WHELAN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-761-8287
Mailing Address - Street 1:PO BOX 95000-3980
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2230
Mailing Address - Country:US
Mailing Address - Phone:212-523-8172
Mailing Address - Fax:212-523-8857
Practice Address - Street 1:425 W 59TH ST STE 7B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-8022
Practice Address - Country:US
Practice Address - Phone:212-523-8172
Practice Address - Fax:212-523-8857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162960-1208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01093645Medicaid
NYA62180Medicare UPIN