Basic Information
| Provider Information | |||||||||
| NPI: | 1962030999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN AFFILIATE GROUP OF NEW YORK PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JACOBI MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 W 125TH ST RM 1001 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175749878 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 PELHAM PKWY S | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104611138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189185000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2020 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEWENSOHN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9144038985 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHYSICIAN AFFILLIATE GROUP OF NEW YORK | ||||||||
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| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.