Provider Demographics
NPI:1891937157
Name:IMPERIAL MEDICAL, PC
Entity Type:Organization
Organization Name:IMPERIAL MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BULA
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:917-658-6470
Mailing Address - Street 1:3-9 SICKLES ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-1642
Mailing Address - Country:US
Mailing Address - Phone:212-304-0096
Mailing Address - Fax:212-304-0037
Practice Address - Street 1:3-9 SICKLES ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-1642
Practice Address - Country:US
Practice Address - Phone:212-304-0096
Practice Address - Fax:212-304-0037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01663872Medicaid
NYWET781Medicare PIN