Healthcare Provider Details

I. General information

NPI: 1669178596
Provider Name (Legal Business Name): FIFTH AVENUE PSYCHIATRY ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 E 85TH ST STE 1A
NEW YORK NY
10028-0417
US

IV. Provider business mailing address

3 E 85TH ST
NEW YORK NY
10028-0417
US

V. Phone/Fax

Practice location:
  • Phone: 212-734-0506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL GLAZER
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 212-734-9859