Provider Demographics
NPI:1902180011
Name:ST. LUKE'S ROOSEVELT HOSPITAL
Entity Type:Organization
Organization Name:ST. LUKE'S ROOSEVELT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-523-7326
Mailing Address - Street 1:1000 10TH AVE
Mailing Address - Street 2:3A-02
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1147
Mailing Address - Country:US
Mailing Address - Phone:212-523-7326
Mailing Address - Fax:
Practice Address - Street 1:1000 10TH AVE
Practice Address - Street 2:3A-02
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1147
Practice Address - Country:US
Practice Address - Phone:212-523-7326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY421032261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility