Healthcare Provider Details

I. General information

NPI: 1831211663
Provider Name (Legal Business Name): JERRY G BLAIVAS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E 77TH ST
NEW YORK NY
10021-2318
US

IV. Provider business mailing address

445 E 77TH ST
NEW YORK NY
10021-2318
US

V. Phone/Fax

Practice location:
  • Phone: 212-772-3900
  • Fax: 212-772-1919
Mailing address:
  • Phone: 212-772-3900
  • Fax: 212-772-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number60144945
License Number StateNY

VIII. Authorized Official

Name: DR. JERRY G BLAIVAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 212-772-3900