Provider Demographics
NPI:1881053775
Name:EXCELSIOR INTEGRATED MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:EXCELSIOR INTEGRATED MEDICAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-335-0328
Mailing Address - Street 1:94 BOWERY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4888
Mailing Address - Country:US
Mailing Address - Phone:212-335-0328
Mailing Address - Fax:
Practice Address - Street 1:758 61ST ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-4212
Practice Address - Country:US
Practice Address - Phone:718-522-1118
Practice Address - Fax:212-335-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-19
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250205174400000X
NY228377174400000X
261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty