Provider Demographics
NPI:1912417254
Name:UPPER WEST SIDE MEDICAL DOCTOR PLLC
Entity Type:Organization
Organization Name:UPPER WEST SIDE MEDICAL DOCTOR PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BHAVANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRANTHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-429-6513
Mailing Address - Street 1:46 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3633
Mailing Address - Country:US
Mailing Address - Phone:732-429-6513
Mailing Address - Fax:917-472-1525
Practice Address - Street 1:46 W 86TH ST STE 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3633
Practice Address - Country:US
Practice Address - Phone:908-962-1000
Practice Address - Fax:908-962-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-30
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY287857OtherNY STATE LICENSE