Basic Information
| Provider Information | |||||||||
| NPI: | 1154369783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYCKOFF EMERGENCY MEDICINE SERVICES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 STOCKHOLM ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112374006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189636551 | ||||||||
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| Practice Location | |||||||||
| Address1: | 374 STOCKHOLM ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112374006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189636551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | IRIZARRY | ||||||||
| AuthorizedOfficialFirstName: | LISANDRO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7189636551 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03307811 | 05 | NY | MEDICAID |