Basic Information
| Provider Information | |||||||||
| NPI: | 1669144036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POTOMAC HEALTH MEDICAL OF NY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1177 HIGH RIDGE RD | ||||||||
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| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06905 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 1177 HIGH RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602820833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2021 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | KIMMEL | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8602820833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.