Basic Information
| Provider Information | |||||||||
| NPI: | 1922128826 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST 49TH STREET E.R. PHYSICIAN CORP. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1475 W 49TH ST | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055582500 | ||||||||
| FaxNumber: | 3058269002 | ||||||||
| Practice Location | |||||||||
| Address1: | 1475 W 49TH ST | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055582500 | ||||||||
| FaxNumber: | 3058269002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 10/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | EARLY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3058244703 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207PE0004X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 059554300 | 05 | FL | MEDICAID |