Healthcare Provider Details

I. General information

NPI: 1407943202
Provider Name (Legal Business Name): ICD CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 E 24TH ST
NEW YORK NY
10010-4019
US

IV. Provider business mailing address

2350 OCEAN AVE APT 7F
BROOKLYN NY
11229-3043
US

V. Phone/Fax

Practice location:
  • Phone: 212-585-6271
  • Fax:
Mailing address:
  • Phone: 212-585-6271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number087199
License Number StateNY

VIII. Authorized Official

Name: GEORGE KONSTANTINE SAMIOS
Title or Position: PSYCHIATRIST
Credential: MD
Phone: 212-585-6271