Healthcare Provider Details

I. General information

NPI: 1235220682
Provider Name (Legal Business Name): FIFTH AVENUE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 5TH AVE
NEW YORK NY
10028-0115
US

IV. Provider business mailing address

1049 5TH AVE
NEW YORK NY
10028-0115
US

V. Phone/Fax

Practice location:
  • Phone: 212-772-6667
  • Fax: 212-988-8018
Mailing address:
  • Phone: 212-772-6667
  • Fax: 212-988-8018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7002195R
License Number StateNY

VIII. Authorized Official

Name: MR. CHARLES J RAAB
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 212-772-6667