Healthcare Provider Details

I. General information

NPI: 1326595364
Provider Name (Legal Business Name): FIFTH AVENUE UROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 E 76TH ST
NEW YORK NY
10021-2676
US

IV. Provider business mailing address

4 E 76TH ST
NEW YORK NY
10021-2676
US

V. Phone/Fax

Practice location:
  • Phone: 631-827-8159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MATHEW JAMES
Title or Position: BILLING MANAGER
Credential:
Phone: 631-827-8159