Basic Information
| Provider Information | |||||||||
| NPI: | 1952067605 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITY MEDICAL OF UPPER EAST SIDE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 RXR PLZ | ||||||||
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| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115561301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164530435 | ||||||||
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| Practice Location | |||||||||
| Address1: | 234 W JERICHO TPKE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117463628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314235400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2021 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEBENGER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9087906567 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CITY MEDICAL OF UPPER EAST SIDE, PLLC | ||||||||
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| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.