Healthcare Provider Details

I. General information

NPI: 1538269444
Provider Name (Legal Business Name): TRUSTEES OF COLUMBIA UNIVERSITY IN THE CITY OF NEW YORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W 168TH ST VC15-207
NEW YORK NY
10032-3725
US

IV. Provider business mailing address

630 W 168TH ST VC15-207
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-2155
  • Fax: 212-927-9704
Mailing address:
  • Phone: 212-305-2155
  • Fax: 212-927-9704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK MCDOUGLE
Title or Position: SVP/CHIEF OPERATING OFFICER
Credential:
Phone: 212-305-6607