Healthcare Provider Details

I. General information

NPI: 1891848461
Provider Name (Legal Business Name): BIMC FACULTY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 UNION SQ E SUITE 2Q
NEW YORK NY
10003-3314
US

IV. Provider business mailing address

PO BOX 95000-2445
PHILADELPHIA PA
19195-2445
US

V. Phone/Fax

Practice location:
  • Phone: 212-844-8888
  • Fax: 212-844-6437
Mailing address:
  • Phone: 212-844-6890
  • Fax: 212-844-6437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH HACKETT
Title or Position: VP
Credential:
Phone: 212-256-3424