Provider Demographics
NPI:1851711410
Name:BRADLEY WASSERMAN, M.D., PLLC
Entity Type:Organization
Organization Name:BRADLEY WASSERMAN, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WASSERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-750-1110
Mailing Address - Street 1:630 1ST AVE
Mailing Address - Street 2:APT 20G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3700
Mailing Address - Country:US
Mailing Address - Phone:718-966-6869
Mailing Address - Fax:718-989-6995
Practice Address - Street 1:630 1ST AVE
Practice Address - Street 2:APT 20G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3700
Practice Address - Country:US
Practice Address - Phone:718-966-6869
Practice Address - Fax:718-989-6995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246054207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty