Basic Information
Provider Information | |||||||||
NPI: | 1124199252 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CITY MEDICAL OF UPPER EAST SIDE, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CITYMD URGENT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1345 RXR PLZ | ||||||||
Address2: |   | ||||||||
City: | UNIONDALE | ||||||||
State: | NY | ||||||||
PostalCode: | 115561301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5167834600 | ||||||||
FaxNumber: | 5167834612 | ||||||||
Practice Location | |||||||||
Address1: | 585 MERRICK RD | ||||||||
Address2: |   | ||||||||
City: | LYNBROOK | ||||||||
State: | NY | ||||||||
PostalCode: | 115632311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5167642273 | ||||||||
FaxNumber: | 5167642268 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2006 | ||||||||
LastUpdateDate: | 08/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEBENGER | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9087906567 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CITY MEDICAL OF UPPER EAST SIDE,PLLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.