Basic Information
Provider Information
NPI: 1053436600
EntityType: 2
ReplacementNPI:  
OrganizationName: CONVENIENT CARE MEDICAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 48 ROUTE 6 & MAHOPAC AVE
Address2:  
City: YORKTOWN HEIGHTS
State: NY
PostalCode: 10598
CountryCode: US
TelephoneNumber: 9142485556
FaxNumber: 9142484091
Practice Location
Address1: 48 RTE 6 & MAHOPAC AVE
Address2:  
City: YORKTOWN HEIGHTS
State: NY
PostalCode: 10598
CountryCode: US
TelephoneNumber: 9142485556
FaxNumber: 9142484091
Other Information
ProviderEnumerationDate: 03/20/2007
LastUpdateDate: 12/25/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: KOO
AuthorizedOfficialFirstName: JIM
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 9142485556
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X151663-1NYY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


Home