Basic Information
| Provider Information | |||||||||
| NPI: | 1093773194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'DONNELL | ||||||||
| FirstName: | MAX | ||||||||
| MiddleName: | ROE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | PH 8 - 101 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123059819 | ||||||||
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| Practice Location | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | PH 8 -101 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123059819 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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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 | 207RP1001X | 235535 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 235535 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | 235535 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00235535 | 05 | NY | MEDICAID |