Basic Information
| Provider Information | |||||||||
| NPI: | 1023238714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT KISCO MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 S BEDFORD RD | ||||||||
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| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105493412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1940 COMMERCE ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | YORKTOWN HTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105984428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149625577 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MONACO | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9142411050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00547351 | 05 | NY | MEDICAID |