Provider Demographics
NPI:1780994913
Name:MANHATTAN MEDICAL PHYSICIAN PLLC
Entity type:Organization
Organization Name:MANHATTAN MEDICAL PHYSICIAN PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-427-1642
Mailing Address - Street 1:1150 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1244
Mailing Address - Country:US
Mailing Address - Phone:212-427-1642
Mailing Address - Fax:646-351-0685
Practice Address - Street 1:1150 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1244
Practice Address - Country:US
Practice Address - Phone:212-427-1642
Practice Address - Fax:646-351-0685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2327981207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02642831Medicaid
NY2327981OtherNY LICENSE
I22894Medicare UPIN
NY260AR1Medicare Oscar/Certification