=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114146172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW YORK GENERAL SURGERY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1160 5TH AVE OFC 105
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-6932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-861-2217
-----------------------------------------------------
Fax | 212-861-1801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1160 5TH AVE OFC 105
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-6932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-861-2217
-----------------------------------------------------
Fax | 212-861-1801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. FREDRIC DAVID HARRIS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 212-861-2217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086X0206X
-----------------------------------------------------
Taxonomy Name | Surgical Oncology Physician
-----------------------------------------------------
License Number | 132817
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------