Basic Information
| Provider Information | |||||||||
| NPI: | 1235699810 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | GORMAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100104605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6465180163 | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100104605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6465180163 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 261QU0200X | 315431 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.