Healthcare Provider Details

I. General information

NPI: 1093274680
Provider Name (Legal Business Name): BRIDGE DERMATOPATHOLOGY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 WHITE PLAINS RD FL 6
TARRYTOWN NY
10591-5113
US

IV. Provider business mailing address

560 WHITE PLAINS RD FL 6
TARRYTOWN NY
10591-5113
US

V. Phone/Fax

Practice location:
  • Phone: 914-345-1101
  • Fax:
Mailing address:
  • Phone: 914-345-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARK JACOBSON
Title or Position: OWNER
Credential: MD
Phone: 914-345-1100