1912272592 NPI number — MEDICAL ASSOCIATE OF WALL STREET, P.C.

Table of content: (NPI 1912272592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912272592 NPI number — MEDICAL ASSOCIATE OF WALL STREET, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL ASSOCIATE OF WALL STREET, P.C.
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:
1912272592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
81 HOLLY HILL LN FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWICH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06830-6071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-869-8515
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 MAIDEN LN RM 500
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:
10038-5140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-233-3040
Provider Business Practice Location Address Fax Number:
212-349-7529
Provider Enumeration Date:
03/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GANDELMAN
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
212-233-3040

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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