Basic Information
| Provider Information | |||||||||
| NPI: | 1184627085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RO | ||||||||
| FirstName: | JAE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28064 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100878064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9145937800 | ||||||||
| FaxNumber: | 9145937881 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 BRADHURST AVE | ||||||||
| Address2: | STE 700 | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9145937800 | ||||||||
| FaxNumber: | 9145937857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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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 | 207RC0000X | 128871 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 321573K221 | 01 | NY | PTAN | OTHER | 060023745 | 01 | NY | RAIL ROAD MEDICARE | OTHER | 00238037 | 05 | NY | MEDICAID |