Healthcare Provider Details

I. General information

NPI: 1902042815
Provider Name (Legal Business Name): EXCELCIUM MED GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 FT WASHINGTON AVENUE SUITE 1C
NEW YORK NY
10033-3527
US

IV. Provider business mailing address

435 FT WASHINGTON AVENUE SUITE 1C
NEW YORK NY
10033-3527
US

V. Phone/Fax

Practice location:
  • Phone: 212-923-0408
  • Fax: 212-923-4032
Mailing address:
  • Phone: 212-923-0408
  • Fax: 212-923-4032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number190663
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number190663
License Number StateNY

VIII. Authorized Official

Name: JOSE A GORIS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 212-923-0408