Healthcare Provider Details

I. General information

NPI: 1609283340
Provider Name (Legal Business Name): LILLIAN RODICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE MEMORIAL 8
NEW YORK NY
10065
US

IV. Provider business mailing address

575 LEXINGTON AVE
NEW YORK NY
10022-6102
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-6938
  • Fax:
Mailing address:
  • Phone: 212-746-7576
  • Fax: 212-746-8383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number017680
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: