Provider Demographics
NPI:1912245762
Name:ST. LUKE'S ROOSEVELT HOSPITAL
Entity Type:Organization
Organization Name:ST. LUKE'S ROOSEVELT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-523-3314
Mailing Address - Street 1:43 W 69TH ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-4741
Mailing Address - Country:US
Mailing Address - Phone:646-422-9463
Mailing Address - Fax:
Practice Address - Street 1:43 W 69TH ST APT 3B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-4741
Practice Address - Country:US
Practice Address - Phone:646-422-9463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty