Provider Demographics
NPI:1295901361
Name:OFFICE BASED MEDICAL PC
Entity type:Organization
Organization Name:OFFICE BASED MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-416-4389
Mailing Address - Street 1:67 ROCKYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-2512
Mailing Address - Country:US
Mailing Address - Phone:718-416-4389
Mailing Address - Fax:718-416-3652
Practice Address - Street 1:67 ROCKYWOOD RD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-2512
Practice Address - Country:US
Practice Address - Phone:718-416-4389
Practice Address - Fax:718-416-3652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189533207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01599522Medicaid
NY07372Medicare PIN