Healthcare Provider Details

I. General information

NPI: 1144540964
Provider Name (Legal Business Name): HEATHER SIEDENBURG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ST AVENUE AND E 16TH STREET STATION MEDICAL CENTER
NEW YORK NY
10003-1012
US

IV. Provider business mailing address

472 CARROLL ST STATION MEDICAL CENTER
BROOKLYN NY
11215-1012
US

V. Phone/Fax

Practice location:
  • Phone: 212-420-2377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number274494
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: