Basic Information
| Provider Information | |||||||||
| NPI: | 1447507827 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER PHYSICIANS OF NEW YORK PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EASTSIDE RADIATION ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2865 E COAST HWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CORONA DEL MAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926252236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492073111 | ||||||||
| FaxNumber: | 9496128255 | ||||||||
| Practice Location | |||||||||
| Address1: | 61 E 77TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100751817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127722130 | ||||||||
| FaxNumber: | 9043455841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2012 | ||||||||
| LastUpdateDate: | 06/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | LIPSZTEIN | ||||||||
| AuthorizedOfficialFirstName: | ROBERTO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9043098680 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0354168 | 05 | NY | MEDICAID |