Basic Information
| Provider Information | |||||||||
| NPI: | 1275136723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL SERVICES OF KIPS BAY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 MARCUS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167737500 | ||||||||
| FaxNumber: | 5167737575 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 NORTHERN BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110215323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167737500 | ||||||||
| FaxNumber: | 5167737575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2020 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216058 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.