Basic Information
| Provider Information | |||||||||
| NPI: | 1124069216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AXEN | ||||||||
| FirstName: | RAFAEL | ||||||||
| MiddleName: | Z | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 SOUTH BEDFORD ROAD | ||||||||
| Address2: | |||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105493412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142446789 | ||||||||
| FaxNumber: | 9142421516 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 SOUTH BEDFORD ROAD | ||||||||
| Address2: | |||||||||
| City: | MT. KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142446789 | ||||||||
| FaxNumber: | 9142421516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 09/23/2016 | ||||||||
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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 | 207L00000X | 227630 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | 227630 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 227630 | 01 | NY | LICENSE | OTHER | DB5589 | 01 | NY | GROUP MEDICARE RAILROAD | OTHER |