Healthcare Provider Details

I. General information

NPI: 1457831174
Provider Name (Legal Business Name): PERFORMANCE MEDICAL PRAACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E 56TH ST 3RD FLOOR
NEW YORK NY
10011
US

IV. Provider business mailing address

160 E 56TH ST 3RD FLOOR
NEW YORK NY
10011
US

V. Phone/Fax

Practice location:
  • Phone: 646-866-6076
  • Fax: 917-261-7912
Mailing address:
  • Phone: 646-866-6076
  • Fax: 917-281-7912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number284515
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number284515
License Number StateNY

VIII. Authorized Official

Name: JONATHAN PHILLIPS
Title or Position: OWNER
Credential: MD
Phone: 347-813-0535