Basic Information
Provider Information | |||||||||
NPI: | 1871919811 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CITY MEDICAL OF UPPER EAST SIDE, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CITYMD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1345 RXR PLZ FL 13 | ||||||||
Address2: |   | ||||||||
City: | UNIONDALE | ||||||||
State: | NY | ||||||||
PostalCode: | 115561301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5168460435 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2393 CENTRAL PARK AVENUE | ||||||||
Address2: |   | ||||||||
City: | YONKERS | ||||||||
State: | NY | ||||||||
PostalCode: | 10710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189130828 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2014 | ||||||||
LastUpdateDate: | 02/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEBENGER | ||||||||
AuthorizedOfficialFirstName: | JEFFERY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9087215725 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CITY MEDICAL OF UPPER EAST SIDE PLLC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 02/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.