Basic Information
| Provider Information | |||||||||
| NPI: | 1093739393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRETTHOLZ | ||||||||
| FirstName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 316 E 30TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100168366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126140039 | ||||||||
| FaxNumber: | 2122539631 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 E 30TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100168202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128895544 | ||||||||
| FaxNumber: | 2124811089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 165247 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 01683036 | 05 | NY | MEDICAID |