Provider Demographics
NPI:1336206242
Name:ST LUKES - ROOSEVELT HOSPITAL CENTER
Entity Type:Organization
Organization Name:ST LUKES - ROOSEVELT HOSPITAL CENTER
Other - Org Name:ROOSEVELT HOSPITAL DOCTORS OFFICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-308-1112
Mailing Address - Street 1:PO BOX 95000-2409
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2409
Mailing Address - Country:US
Mailing Address - Phone:212-308-1112
Mailing Address - Fax:212-308-1616
Practice Address - Street 1:780 8TH AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-7017
Practice Address - Country:US
Practice Address - Phone:212-641-4500
Practice Address - Fax:212-641-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEV941Medicare PIN