Basic Information
| Provider Information | |||||||||
| NPI: | 1528061686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DROLLER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUSTAVE L LEVY PL | ||||||||
| Address2: | # 1272 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122414812 | ||||||||
| FaxNumber: | 2129874675 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 E 98TH ST | ||||||||
| Address2: | FL 6 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122414812 | ||||||||
| FaxNumber: | 2129874675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 158347 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00976834 | 05 | NY | MEDICAID |