Basic Information
| Provider Information | |||||||||
| NPI: | 1073524369 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRUSTEES OF COLUMBIA UNIVERSITY IN THE CITY OF NEW YORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASSOCIATES IN EMERGENCY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | PH 1-137 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052995 | ||||||||
| FaxNumber: | 2123056792 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | PH 1-137 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052995 | ||||||||
| FaxNumber: | 2123056792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLATNIK | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | WATERMAN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2123052995 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02441918 | 05 | NY | MEDICAID |