Healthcare Provider Details

I. General information

NPI: 1083069439
Provider Name (Legal Business Name): FIFTH AVENUE MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 5TH AVE SUITE 500
NEW YORK NY
10151-0099
US

IV. Provider business mailing address

745 5TH AVE SUITE 500
NEW YORK NY
10151-0099
US

V. Phone/Fax

Practice location:
  • Phone: 646-898-2037
  • Fax:
Mailing address:
  • Phone: 646-898-2037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number101838
License Number StateNY

VIII. Authorized Official

Name: CHARLES Y JIN
Title or Position: MEMBER
Credential: M.D.
Phone: 646-898-2037