Healthcare Provider Details

I. General information

NPI: 1386953529
Provider Name (Legal Business Name): WESTMIDTOWNMEDICALGROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W 35TH ST
NEW YORK NY
10001-1701
US

IV. Provider business mailing address

311 W 35TH ST
NEW YORK NY
10001-1701
US

V. Phone/Fax

Practice location:
  • Phone: 212-736-5900
  • Fax: 212-643-1441
Mailing address:
  • Phone: 212-736-5900
  • Fax: 212-643-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number17904
License Number StateNY

VIII. Authorized Official

Name: MR. STUART MARTIN FISHMAN
Title or Position: COUNSELOR
Credential: CASAC
Phone: 212-736-5900