Provider Demographics
NPI:1952559874
Name:WEST MIDTOWN MEDICAL GROUP
Entity Type:Organization
Organization Name:WEST MIDTOWN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:O
Authorized Official - Last Name:PANIAGUA
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:212-736-5900
Mailing Address - Street 1:4011 165TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2621
Mailing Address - Country:US
Mailing Address - Phone:917-531-5896
Mailing Address - Fax:212-643-1441
Practice Address - Street 1:311 W 35TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-1701
Practice Address - Country:US
Practice Address - Phone:212-736-5900
Practice Address - Fax:212-643-1441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006339302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01911393Medicaid