Basic Information
| Provider Information | |||||||||
| NPI: | 1700854742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRZOLEK | ||||||||
| FirstName: | MONIKA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1 EDGEWATER ST | ||||||||
| Address2: | 6TH FL. PAYER RELATIONS | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103054900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182261008 | ||||||||
| FaxNumber: | 7182261039 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 EDGEWATER PLAZA | ||||||||
| Address2: | 1ST FL. LAB | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103054900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182264130 | ||||||||
| FaxNumber: | 7182264185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 1923451 | NY | N | Other Service Providers | Specialist | 207ZP0101X | 192345 | NY | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0102X | 192345 | NY | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZN0500X | 192345 | NY | N | Allopathic & Osteopathic Physicians | Pathology | Neuropathology |
ID Information
| ID | Type | State | Issuer | Description | 990002274 | 01 | RAILROAD MEDICARE | OTHER |