=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336258128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW YORK GI CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 04/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 WATERS PL SUITE M117
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10461-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-863-0575
-----------------------------------------------------
Fax | 718-863-2467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 WATERS PL SUITE M117
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10461-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-863-0575
-----------------------------------------------------
Fax | 718-863-2467
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. JAMES COSTABILE DILORENZO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 914-725-9115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0800X
-----------------------------------------------------
Taxonomy Name | Endoscopy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------