Basic Information
| Provider Information | |||||||||
| NPI: | 1144259425 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIRSCHENBAUM | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459873952 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074502502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016704664 | ||||||||
| FaxNumber: | 2016708007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MA04933400 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | 25MA04933400 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 155240 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 155240 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 01113533 | 05 | NY | MEDICAID | 3396100 | 05 | NJ | MEDICAID |