Basic Information
| Provider Information | |||||||||
| NPI: | 1588291512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN AFFILIATE GROUP OF NEW YORK PC | ||||||||
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| OtherOrganizationName: | NORTH CENTRAL BRONX HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 W 125TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175749878 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3424 KOSSUTH AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104672410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185195000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2020 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEWENSOHN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9144038985 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHYSICIAN AFFILLIATE GROUP OF NEW YORK | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.