Healthcare Provider Details

I. General information

NPI: 1609222173
Provider Name (Legal Business Name): SUPPORTIVE MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 MALCOLM X BLVD UNIT 2
NEW YORK NY
10026-1364
US

IV. Provider business mailing address

181 MALCOLM X BLVD UNIT 2
NEW YORK NY
10026-1364
US

V. Phone/Fax

Practice location:
  • Phone: 646-883-2273
  • Fax:
Mailing address:
  • Phone: 646-883-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA THOMPSON
Title or Position: OWNER
Credential: MD
Phone: 505-681-8222