Provider Demographics
NPI:1912272592
Name:MEDICAL ASSOCIATE OF WALL STREET, P.C.
Entity Type:Organization
Organization Name:MEDICAL ASSOCIATE OF WALL STREET, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:GANDELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-233-3040
Mailing Address - Street 1:81 HOLLY HILL LN FL 3
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6071
Mailing Address - Country:US
Mailing Address - Phone:203-869-8515
Mailing Address - Fax:
Practice Address - Street 1:6 MAIDEN LN RM 500
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-5140
Practice Address - Country:US
Practice Address - Phone:212-233-3040
Practice Address - Fax:212-349-7529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty