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General NPI Number Information
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NPI Number | 1295958841
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Entity Type | Organization
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Legal Business Name | EAST SIDE GASTROENTEROLOGY, P.C.
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 111 E 80TH ST 1C
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City | NEW YORK
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State | NY
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Zip | 10021-0334
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Country | US
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Telephone | 212-734-5533
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Fax | 212-717-1688
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Provider Business Mailing Address
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Address Line | 111 E 80TH ST 1C
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City | NEW YORK
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State | NY
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Zip | 10021-0334
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Country | US
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Telephone | 212-734-5533
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Fax | 212-717-1688
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Authorized Official
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Title or Position | ASSISTANT
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Name | MS. SHANTA LIVERMAN
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Credential | CMA
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Telephone | 212-734-5533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 147236
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License Number State | NY
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