Basic Information
Provider Information
NPI: 1417501933
EntityType: 2
ReplacementNPI:  
OrganizationName: CITY MEDICAL OF UPPER EAST SIDE, PLLC
LastName:  
FirstName:  
MiddleName:  
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Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: 1345 RXR PLZ FL 13
Address2:  
City: UNIONDALE
State: NY
PostalCode: 115561301
CountryCode: US
TelephoneNumber: 5164530435
FaxNumber: 6468463283
Practice Location
Address1: 356 W 125TH ST
Address2:  
City: NEW YORK
State: NY
PostalCode: 100274820
CountryCode: US
TelephoneNumber: 6466471267
FaxNumber: 6466471268
Other Information
ProviderEnumerationDate: 08/01/2019
LastUpdateDate: 08/01/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SIMPSON
AuthorizedOfficialFirstName: MARLENA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: VP, CREDENTIALING/ENROLLMENT
AuthorizedOfficialTelephone: 5164530435
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: CITY MEDICAL OF UPPER EAST SIDE, PLLC
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: CPMSM
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QU0200X  Y Ambulatory Health Care FacilitiesClinic/CenterUrgent Care

No ID Information.


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