MEDICARE: DESTINEE SOUBANNARATH GWEE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	036.173686	IL
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1932787389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINEE SOUBANNARATH GWEE

Provider Business Mailing Address
First Line	:	525 E 68TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10065-4870
Country	:	US
Telephone Number	:	212-746-5454
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 E 68TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10065-4870
Country	:	US
Telephone Number	:	212-746-5454
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2021
Last Update Date	:	03/03/2026

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