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General NPI Number Information
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NPI Number | 1487992871
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Entity Type | Organization
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Legal Business Name | RUSSAK DERMATOLOGY PC
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Dates
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Enumeration Date | 01/21/2013
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Last Update Date | 01/21/2013
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Provider Practice Location Address
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Address Line | 115 E 57TH ST 12TH FLOOR
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City | NEW YORK
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State | NY
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Zip | 10022-2049
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Country | US
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Telephone | 212-684-5964
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Fax |
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Provider Business Mailing Address
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Address Line | 115 E 57TH ST 12TH FLOOR
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City | NEW YORK
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State | NY
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Zip | 10022-2049
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Country | US
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Telephone | 212-684-5964
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JULIE E RUSSAK
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Credential | MD
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Telephone | 212-684-5964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 249307-1
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License Number State | NY
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