Basic Information
Provider Information | |||||||||
NPI: | 1275632895 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NYU LANGONE HOSPITALS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14 WALL ST FL 10 | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100052103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002376977 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 301 E 17TH ST | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 10003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2122631481 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2006 | ||||||||
LastUpdateDate: | 03/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | WESLEY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 8002376977 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NYU LANGONE HOSPITALS | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 7002053H | NY | N |   | Hospitals | General Acute Care Hospital |   | 273Y00000X | 7002053H | NY | Y |   | Hospital Units | Rehabilitation Unit |   |
ID Information
ID | Type | State | Issuer | Description | 000290 | 01 | NY | BLUE CROSS | OTHER | 00243389 | 05 | NY |   | MEDICAID |