Provider Demographics
NPI:1912419698
Name:NY COMPREHENSIVE MEDICAL WELLNESS P.C.
Entity Type:Organization
Organization Name:NY COMPREHENSIVE MEDICAL WELLNESS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SORACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-331-9900
Mailing Address - Street 1:2 S END AVE APT TH8
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10280-1089
Mailing Address - Country:US
Mailing Address - Phone:830-331-9900
Mailing Address - Fax:
Practice Address - Street 1:329 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5625
Practice Address - Country:US
Practice Address - Phone:718-585-5500
Practice Address - Fax:718-585-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288165207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY115644OtherNYSED ID