Healthcare Provider Details

I. General information

NPI: 1538351572
Provider Name (Legal Business Name): BIMC FACULTY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 E 17TH ST
NEW YORK NY
10003-3805
US

IV. Provider business mailing address

160 WATER ST 20TH FLOOR
NEW YORK NY
10038-4922
US

V. Phone/Fax

Practice location:
  • Phone: 212-420-2847
  • Fax:
Mailing address:
  • Phone: 212-256-3539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH HACKETT
Title or Position: VP
Credential: MD
Phone: 212-256-3424