Basic Information
| Provider Information | |||||||||
| NPI: | 1013293588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSIO LOGIC MEDICINE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 281 BROADWAY | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100071831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182601000 | ||||||||
| FaxNumber: | 7182600072 | ||||||||
| Practice Location | |||||||||
| Address1: | 409 FULTON STREET | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182601000 | ||||||||
| FaxNumber: | 7182600072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2011 | ||||||||
| LastUpdateDate: | 04/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | KUO | ||||||||
| AuthorizedOfficialFirstName: | JONATHANN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7182601000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 241732 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.