Healthcare Provider Details

I. General information

NPI: 1952559874
Provider Name (Legal Business Name): WEST MIDTOWN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
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

4011 165TH ST
FLUSHING NY
11358-2621
US

V. Phone/Fax

Practice location:
  • Phone: 212-736-5900
  • Fax: 212-643-1441
Mailing address:
  • Phone: 917-531-5896
  • Fax: 212-643-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number006339
License Number StateNY

VIII. Authorized Official

Name: MR. DANIEL O PANIAGUA
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 212-736-5900