Healthcare Provider Details

I. General information

NPI: 1962569921
Provider Name (Legal Business Name): ST. LUKE'S ROOSEVELT HOSPITAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 57TH ST SUITE 1001
NEW YORK NY
10019-3211
US

IV. Provider business mailing address

PO BOX 95000-2388
PHILADELPHIA PA
19195-2388
US

V. Phone/Fax

Practice location:
  • Phone: 212-663-6604
  • Fax: 212-663-7259
Mailing address:
  • Phone: 212-308-1112
  • Fax: 212-308-1616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK GRAY
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 212-308-1112