Provider Demographics
NPI:1902042815
Name:EXCELCIUM MED GROUP, PC
Entity Type:Organization
Organization Name:EXCELCIUM MED GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-923-0408
Mailing Address - Street 1:435 FT WASHINGTON AVENUE
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3527
Mailing Address - Country:US
Mailing Address - Phone:212-923-0408
Mailing Address - Fax:212-923-4032
Practice Address - Street 1:435 FT WASHINGTON AVENUE
Practice Address - Street 2:SUITE 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3527
Practice Address - Country:US
Practice Address - Phone:212-923-0408
Practice Address - Fax:212-923-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190663207ZP0102X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01740610Medicaid
190663OtherLICENSE
190663OtherLICENSE
BG3446425OtherDEA
NY01740610Medicaid