Basic Information
| Provider Information | |||||||||
| NPI: | 1710912100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIN | ||||||||
| FirstName: | HENRY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CITY PLACE | ||||||||
| Address2: | APT 23C | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144379006 | ||||||||
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| Practice Location | |||||||||
| Address1: | 622 WEST 168TH ST | ||||||||
| Address2: | PH-1-137 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052995 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 09/26/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/19/2006 | ||||||||
| NPIReactivationDate: | 10/24/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 232280 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 039795 | CT | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02419056 | 05 | NY | MEDICAID |