Healthcare Provider Details

I. General information

NPI: 1528378668
Provider Name (Legal Business Name): ST KILDA MEDICAL SERVICE,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1067 5TH AVE
NEW YORK NY
10128-0101
US

IV. Provider business mailing address

1067 5TH AVE
NEW YORK NY
10128-0101
US

V. Phone/Fax

Practice location:
  • Phone: 212-874-3384
  • Fax: 212-874-0031
Mailing address:
  • Phone: 212-874-3384
  • Fax: 212-874-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number156442
License Number StateNY

VIII. Authorized Official

Name: BLAIR S LEWIS
Title or Position: OWNER
Credential: MD
Phone: 212-874-3384