Healthcare Provider Details

I. General information

NPI: 1134211717
Provider Name (Legal Business Name): ST LUKES ROOSEVELT HOSPITAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 10TH AVE
NEW YORK NY
10019-1147
US

IV. Provider business mailing address

407 AIRPORT EXECUTIVE PARK
NANUET NY
10954-5288
US

V. Phone/Fax

Practice location:
  • Phone: 212-523-6745
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name: DAN WIENER
Title or Position: GROUP DIRECTOR
Credential: MD
Phone: 212-523-3981