Healthcare Provider Details

I. General information

NPI: 1124232939
Provider Name (Legal Business Name): CORINTHIAN MEDICAL IPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 FORT WASHINGTON AVE
NEW YORK NY
10033-4654
US

IV. Provider business mailing address

481 FORT WASHINGTON AVE
NEW YORK NY
10033-4654
US

V. Phone/Fax

Practice location:
  • Phone: 212-740-8294
  • Fax: 212-740-8289
Mailing address:
  • Phone: 212-740-8294
  • Fax: 212-740-8289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number StateNY

VIII. Authorized Official

Name: DR. RAMON MODESTO TALLAJ
Title or Position: PRESIDENT
Credential: MD
Phone: 212-740-8294