Basic Information
| Provider Information | |||||||||
| NPI: | 1669412847 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUR LADY OF MERCY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OUR LADY OF MERCY EMGERGENCY DEPT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 W 34TH ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100013007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125632497 | ||||||||
| FaxNumber: | 2125630605 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 E 233RD ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104662604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189209135 | ||||||||
| FaxNumber: | 7189209100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEVITON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7189209135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PP0204X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01003516 | 05 | NY | MEDICAID |