Healthcare Provider Details

I. General information

NPI: 1164266334
Provider Name (Legal Business Name): THREE RIVERS MEDICAL OF NEW YORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2024
Last Update Date: 06/22/2024
Certification Date: 06/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 OCEAN PKWY
BROOKLYN NY
11235-7745
US

IV. Provider business mailing address

1511 3RD AVE STE 1000
SEATTLE WA
98101-3637
US

V. Phone/Fax

Practice location:
  • Phone: 917-540-0837
  • Fax:
Mailing address:
  • Phone: 805-608-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL M WASSER
Title or Position: MANAGER
Credential:
Phone: 805-608-3600