Basic Information
| Provider Information | |||||||||
| NPI: | 1689740193 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KWA | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 W 52ND ST | ||||||||
| Address2: | 3RD FLR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100196239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467542100 | ||||||||
| FaxNumber: | 6467542115 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 W 52ND ST | ||||||||
| Address2: | 3RD FLR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100196239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467542100 | ||||||||
| FaxNumber: | 6467542115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 224451 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | BK8410146 | 01 | CT | DEA NUMBER | OTHER | 224451 | 01 | NY | NY STATE LICENSE | OTHER |