Healthcare Provider Details

I. General information

NPI: 1477325413
Provider Name (Legal Business Name): GREENWICH STREET MEDICAL SERVICES OF NEW YORK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 GREENWICH ST
NEW YORK NY
10014-3610
US

IV. Provider business mailing address

609 GREENWICH ST
NEW YORK NY
10014-3610
US

V. Phone/Fax

Practice location:
  • Phone: 212-261-6542
  • Fax: 505-212-0553
Mailing address:
  • Phone: 212-261-6542
  • Fax: 505-212-0553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHONNIUSS CHEMWENO
Title or Position: TPA CEO
Credential:
Phone: 212-261-6542