Basic Information
| Provider Information | |||||||||
| NPI: | 1558442426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYCONN ORTHOPAEDIC & REHABILITATION SPECIALISTS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 WESTCHESTER AVE | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | PURCHASE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105772552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142497000 | ||||||||
| FaxNumber: | 9142497034 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HARRISON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106042917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146846113 | ||||||||
| FaxNumber: | 9146842740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | DOWDLE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9142497000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 02736625004 | 05 | NY | MEDICAID |