=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528349933
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER WEST SIDE MEDICAL P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2011
-----------------------------------------------------
Last Update Date | 10/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 W 79TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10024-6454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-785-1059
-----------------------------------------------------
Fax | 212-269-2901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3234 CHURCH STREET STATION
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10008-3234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-785-1059
-----------------------------------------------------
Fax | 212-269-2901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. RAPHAEL A CASTILLO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 646-267-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 257247
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 232065-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------