Basic Information
| Provider Information | |||||||||
| NPI: | 1518257302 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARDEN CITY PROFESSIONAL OFFICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 BANK ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
| FaxNumber: | 4065497559 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 BANK ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
| FaxNumber: | 4065497559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | BORNSTEIN | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4065497325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.