Basic Information
| Provider Information | |||||||||
| NPI: | 1518943802 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARTSDALE MEDICAL GROUP, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 180 E HARTSDALE AVE | ||||||||
| Address2: | SUITE 1E | ||||||||
| City: | HARTSDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105303544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147252010 | ||||||||
| FaxNumber: | 9147256488 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 E HARTSDALE AVE | ||||||||
| Address2: | SUITE 1E | ||||||||
| City: | HARTSDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105303544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147252010 | ||||||||
| FaxNumber: | 9147256488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHAIT | ||||||||
| AuthorizedOfficialFirstName: | MAXWELL | ||||||||
| AuthorizedOfficialMiddleName: | MANI | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9147252010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RG0100X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RH0003X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00599748 | 05 | NY | MEDICAID |