Healthcare Provider Details

I. General information

NPI: 1720638497
Provider Name (Legal Business Name): TRIBOROUGH ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 E 180TH ST
BRONX NY
10457-3304
US

IV. Provider business mailing address

2076 E 13TH ST
BROOKLYN NY
11229-3304
US

V. Phone/Fax

Practice location:
  • Phone: 718-382-7900
  • Fax: 718-382-7901
Mailing address:
  • Phone: 718-382-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK GLADSTEIN
Title or Position: OWNER
Credential: MD
Phone: 718-382-7900