Healthcare Provider Details

I. General information

NPI: 1790904878
Provider Name (Legal Business Name): MOUNT KISCO MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BEDFORD RD
KATONAH NY
10536
US

IV. Provider business mailing address

90 SOUTH BEDFORD RD
MOUNT KISCO NY
10549
US

V. Phone/Fax

Practice location:
  • Phone: 914-232-3135
  • Fax:
Mailing address:
  • Phone: 914-241-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN MONACO
Title or Position: BILLING DIRECTOR
Credential:
Phone: 914-241-1050