Healthcare Provider Details

I. General information

NPI: 1215172242
Provider Name (Legal Business Name): BETH ISRAEL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 E 17TH ST FL 1
NEW YORK NY
10003-3804
US

IV. Provider business mailing address

317 E 17TH ST FL 1
NEW YORK NY
10003-3804
US

V. Phone/Fax

Practice location:
  • Phone: 212-420-2307
  • Fax: 212-420-3971
Mailing address:
  • Phone: 212-420-2307
  • Fax: 212-420-3971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number038499
License Number StateNY

VIII. Authorized Official

Name: MR. JOHN MALCOLM SAMUELS
Title or Position: ADMINISTRATIVE DIRECTOR OF AIDS SVC
Credential: MPH
Phone: 212-420-5693