1063733863 NPI number — BESPOKE SURGICAL, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063733863 NPI number — BESPOKE SURGICAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BESPOKE SURGICAL, PC
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:
1063733863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 7TH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10014-2727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-206-1501
Provider Business Mailing Address Fax Number:
888-880-8621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 7TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10014-2727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-206-1501
Provider Business Practice Location Address Fax Number:
888-880-8621
Provider Enumeration Date:
06/15/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOLDSTEIN
Authorized Official First Name:
EVAN
Authorized Official Middle Name:
BRAD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
917-570-4437

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , 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)