=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184058992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HCA IN MEDICINE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2013
-----------------------------------------------------
Last Update Date | 05/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 E 58TH ST STE 504
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-886-1097
-----------------------------------------------------
Fax | 718-967-6023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2535 ARTHUR KILL RD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10309-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-448-3210
-----------------------------------------------------
Fax | 718-984-2642
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO & ADMINISTRATOR
-----------------------------------------------------
Name | MR. PAUL I BERKLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-448-3210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------