Basic Information
| Provider Information | |||||||||
| NPI: | 1912096595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KISELAK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S BEDFORD RD | ||||||||
| Address2: | CAREMOUNT MEDICAL PC | ||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105493446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
| FaxNumber: | 9142421516 | ||||||||
| Practice Location | |||||||||
| Address1: | 672 STONELEIGH AVE | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105124634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452792000 | ||||||||
| FaxNumber: | 8452788986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 181986 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 01215049 | 05 | NY | MEDICAID |