Healthcare Provider Details

I. General information

NPI: 1003419557
Provider Name (Legal Business Name): MEDICAL SERVICES OF KIPS BAY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 LAKEVILLE RD STE 303
NEW HYDE PARK NY
11042-1104
US

IV. Provider business mailing address

2000 MARCUS AVE
NEW HYDE PARK NY
11042-1069
US

V. Phone/Fax

Practice location:
  • Phone: 516-321-7555
  • Fax: 516-321-7831
Mailing address:
  • Phone: 516-321-7555
  • Fax: 516-321-7831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELE L CUSACK
Title or Position: SENIOR VICE PRESIDENT & CFO
Credential:
Phone: 516-321-6058