Healthcare Provider Details

I. General information

NPI: 1740559012
Provider Name (Legal Business Name): TRIFECTA HEALTH MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 BROADWAY STE. 1300
NEW YORK NY
10006-1604
US

IV. Provider business mailing address

115 BROADWAY STE. 1300
NEW YORK NY
10006-1604
US

V. Phone/Fax

Practice location:
  • Phone: 212-233-2830
  • Fax: 888-348-5193
Mailing address:
  • Phone: 212-233-2830
  • Fax: 888-348-5193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number747423UPD
License Number StateNY

VIII. Authorized Official

Name: DR. EDWARD FRUITMAN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 212-233-2830