Basic Information
| Provider Information | |||||||||
| NPI: | 1104934736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRUCHNICKI | ||||||||
| FirstName: | ALEC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 W 33RD ST | ||||||||
| Address2: | PBS 12TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100012603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123564474 | ||||||||
| FaxNumber: | 2123564608 | ||||||||
| Practice Location | |||||||||
| Address1: | 1261 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100293822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125345400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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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 | 208D00000X | 182266 | NY | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 02229138 | 05 | NY | MEDICAID |