Healthcare Provider Details

I. General information

NPI: 1699819433
Provider Name (Legal Business Name): SISCK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914A COLUMBUS AVE
NEW YORK NY
10025-4040
US

IV. Provider business mailing address

914A COLUMBUS AVE
NEW YORK NY
10025-4040
US

V. Phone/Fax

Practice location:
  • Phone: 212-749-2482
  • Fax: 212-749-2484
Mailing address:
  • Phone: 212-749-2482
  • Fax: 212-749-2484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number226508
License Number StateNY

VIII. Authorized Official

Name: GODFREY U MBONU
Title or Position: PRESIDENT
Credential: MD
Phone: 212-749-2482