Basic Information
| Provider Information | |||||||||
| NPI: | 1174508360 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUKES ROOSEVELT HOSPITAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PERINATAL ASSOCIATES OF SLR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000-4930 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191954930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163385300 | ||||||||
| FaxNumber: | 5163331075 | ||||||||
| Practice Location | |||||||||
| Address1: | PRIMARY 1000 10TH AVENUE, STE 11A-61 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125238110 | ||||||||
| FaxNumber: | 2125233472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | SINGERMAN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2125233452 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01570034 | 05 | NY | MEDICAID |