Provider Demographics
NPI:1881770956
Name:GOUREVITCH, MARC (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:GOUREVITCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 1ST AVE
Mailing Address - Street 2:OBV A-618
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-8553
Mailing Address - Fax:212-263-8788
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:OBV A-618
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-8553
Practice Address - Fax:212-263-8788
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174812207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01714130Medicaid
NYF23922Medicare UPIN
NY059AN1Medicare ID - Type Unspecified