Provider Demographics
NPI:1255023628
Name:INTEGRATED REPRODUCTIVE SURGERY LLC
Entity type:Organization
Organization Name:INTEGRATED REPRODUCTIVE SURGERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-515-6129
Mailing Address - Street 1:204 CORLIES AVE
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803-1904
Mailing Address - Country:US
Mailing Address - Phone:646-844-9602
Mailing Address - Fax:
Practice Address - Street 1:779 NORTH ST
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-3105
Practice Address - Country:US
Practice Address - Phone:646-844-9602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-24
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1538393194OtherNPI
NY1235574559OtherNPI