Healthcare Provider Details

I. General information

NPI: 1609263177
Provider Name (Legal Business Name): FPA OUT OF NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE GUSTAVE L. LEVY PLACE
NEW YORK NY
10029-6574
US

IV. Provider business mailing address

PO BOX 28082
NEW YORK NY
10087-8082
US

V. Phone/Fax

Practice location:
  • Phone: 646-605-8119
  • Fax: 646-605-3029
Mailing address:
  • Phone: 646-605-8119
  • Fax: 646-605-3029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CRYSTAL MACNEILL
Title or Position: VICE PRESIDENT, CBO DIRECTOR
Credential:
Phone: 646-605-8112