Basic Information
| Provider Information | |||||||||
| NPI: | 1134114549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIPPEL | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1305 YORK AVE | ||||||||
| Address2: | 12TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100215663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6469622020 | ||||||||
| FaxNumber: | 6469620604 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 YORK AVE | ||||||||
| Address2: | 12TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100215663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6469622020 | ||||||||
| FaxNumber: | 6469620604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0120X | 241758 | NY | Y |
ID Information
| ID | Type | State | Issuer | Description | 02817563 | 05 | NY | MEDICAID |