1447677471 NPI number — MACULA EYE CARE OPHTHALMOLOGY PLLC

Table of content: (NPI 1447677471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447677471 NPI number — MACULA EYE CARE OPHTHALMOLOGY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACULA EYE CARE OPHTHALMOLOGY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447677471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
157 W 79TH ST
Provider Second Line Business Mailing Address:
7 A
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10024-6413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-877-9109
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67 E 78TH ST
Provider Second Line Business Practice Location Address:
1 C
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10075-0273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-744-2513
Provider Business Practice Location Address Fax Number:
212-744-4816
Provider Enumeration Date:
03/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
EVA
Authorized Official Title or Position:
FOUNDER/PHYSICIAN
Authorized Official Telephone Number:
610-636-1879

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  072039L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 224954 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1295729762 . This is a "NPI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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