Healthcare Provider Details

I. General information

NPI: 1043790355
Provider Name (Legal Business Name): IDUHA IPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W 38TH ST
NEW YORK NY
10018-2913
US

IV. Provider business mailing address

307 W 38TH ST ROOM 03-049
NEW YORK NY
10018-2913
US

V. Phone/Fax

Practice location:
  • Phone: 718-637-3045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: KEVIN MUIR
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 718-637-3045