Healthcare Provider Details

I. General information

NPI: 1366871378
Provider Name (Legal Business Name): KEZMED MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2013
Last Update Date: 11/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 WOODS END RD N
DIX HILLS NY
11746-5934
US

IV. Provider business mailing address

228 PARK AVE S #36910
NEW YORK NY
10003-1502
US

V. Phone/Fax

Practice location:
  • Phone: 347-860-1900
  • Fax:
Mailing address:
  • Phone: 347-860-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number262198-1
License Number StateNY

VIII. Authorized Official

Name: ANDREW ORMSON
Title or Position: CREDENTIALER
Credential:
Phone: 917-945-5436