Healthcare Provider Details

I. General information

NPI: 1144231226
Provider Name (Legal Business Name): SPORTS MEDICINE AT CHELSEA, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W 24TH ST FL 2
NEW YORK NY
10010-3560
US

IV. Provider business mailing address

30 W 24TH ST FL 2
NEW YORK NY
10010-3560
US

V. Phone/Fax

Practice location:
  • Phone: 212-366-5100
  • Fax: 212-366-6275
Mailing address:
  • Phone: 212-366-5100
  • Fax: 212-366-6275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2247351
License Number StateNY

VIII. Authorized Official

Name: CLIFFORD D STARK
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 212-366-5100