Healthcare Provider Details

I. General information

NPI: 1346397023
Provider Name (Legal Business Name): MARY LYNN CHU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E 17TH ST
NEW YORK NY
10003-3804
US

IV. Provider business mailing address

135 E 71ST ST 12-C
NEW YORK NY
10021-4258
US

V. Phone/Fax

Practice location:
  • Phone: 212-598-6203
  • Fax: 212-598-6130
Mailing address:
  • Phone: 212-598-6203
  • Fax: 212-598-6130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number161562
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: