Basic Information
| Provider Information | |||||||||
| NPI: | 1003056268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASSERMAN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 BRADHURST AVE | ||||||||
| Address2: | SUITE 3070N | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143727887 | ||||||||
| FaxNumber: | 9143727884 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 BRADHURST AVE | ||||||||
| Address2: | SUITE 3070N | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143727887 | ||||||||
| FaxNumber: | 9143727884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2009 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 239748 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | A97716 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 278234 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 110082710A | 05 | MA | MEDICAID |