Basic Information
| Provider Information | |||||||||
| NPI: | 1437143005 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | MARIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 CATHARINE ST | ||||||||
| Address2: | P.O. BOX 550 | ||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126013100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457902661 | ||||||||
| FaxNumber: | 8457902675 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 E 88TH ST | ||||||||
| Address2: | JAN J. SHIM, MD | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101280509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125355020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 10/18/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 163229-1 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00916885 | 05 | NY | MEDICAID |