1962612507 NPI number — SRB PLASTIC SURGERY PC

Table of content: (NPI 1962612507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962612507 NPI number — SRB PLASTIC SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SRB PLASTIC SURGERY 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:
1962612507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
SRB PLASTIC SURGERY PC
Provider Second Line Business Mailing Address:
75 E 71ST STREET
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10021-4251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-879-7900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 PARK AVE
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:
10021-4251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-879-7900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BROUMAND
Authorized Official First Name:
STAFFORD
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
212-879-7900

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  166718 , 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: 0100923 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: N37868 . This is a "HEALTH NET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 80H671 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P3806444 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".