Basic Information
| Provider Information | |||||||||
| NPI: | 1386644128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARRICK | ||||||||
| FirstName: | RENEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 BRADHURST AVE | ||||||||
| Address2: | SUITE 200N | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144937701 | ||||||||
| FaxNumber: | 9143450653 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 BRADHURST AVE | ||||||||
| Address2: | SUITE 200N | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144937701 | ||||||||
| FaxNumber: | 9143450653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 140904 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 00904632 | 05 | NY | MEDICAID |