Healthcare Provider Details

I. General information

NPI: 1588823652
Provider Name (Legal Business Name): FIFTH AVENUE MILLENNIUM AESTHETIC SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 5TH AVE
NEW YORK NY
10128-0143
US

IV. Provider business mailing address

1125 5TH AVE
NEW YORK NY
10128-0143
US

V. Phone/Fax

Practice location:
  • Phone: 212-288-9800
  • Fax: 212-860-7446
Mailing address:
  • Phone: 212-288-9800
  • Fax: 212-860-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. LEO KEEGAN
Title or Position: PARTNER
Credential: M.D.
Phone: 212-288-9800