Basic Information
Provider Information | |||||||||
NPI: | 1790904878 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOUNT KISCO MEDICAL GROUP PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 90 SOUTH BEDFORD RD | ||||||||
Address2: |   | ||||||||
City: | MOUNT KISCO | ||||||||
State: | NY | ||||||||
PostalCode: | 10549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9142411050 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 111 BEDFORD RD | ||||||||
Address2: |   | ||||||||
City: | KATONAH | ||||||||
State: | NY | ||||||||
PostalCode: | 10536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9142323135 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONACO | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9142411050 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208000000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 208800000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 00547351 | 05 | NY |   | MEDICAID |