Healthcare Provider Details

I. General information

NPI: 1689871238
Provider Name (Legal Business Name): LENOX OTOLARYNGOLOGY HEAD & NECK SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 5TH AVE RM 709
NEW YORK NY
10001-2211
US

IV. Provider business mailing address

186 E 76TH ST 2ND FLOOR
NEW YORK NY
10021-2844
US

V. Phone/Fax

Practice location:
  • Phone: 212-629-3223
  • Fax: 212-629-3466
Mailing address:
  • Phone: 212-434-2323
  • Fax: 212-434-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

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