=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336147859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAMERCY CARDIAC DIAGNOSTIC SERVICES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2005
-----------------------------------------------------
Last Update Date | 10/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 W 35TH ST FLOOR 7
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-475-8066
-----------------------------------------------------
Fax | 212-475-4175
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 W 35TH ST FLOOR 7
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-475-8066
-----------------------------------------------------
Fax | 212-475-4175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRECERTIFICATION/CREDENTIALS
-----------------------------------------------------
Name | MISS VICTORIA MARIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-475-8066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207UN0901X
-----------------------------------------------------
Taxonomy Name | Nuclear Cardiology Physician
-----------------------------------------------------
License Number | 60-144465-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------