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General NPI Number Information
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NPI Number | 1528378668
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Entity Type | Organization
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Legal Business Name | ST KILDA MEDICAL SERVICE,PLLC
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Dates
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Enumeration Date | 10/07/2010
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Last Update Date | 07/21/2011
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Provider Practice Location Address
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Address Line | 1067 5TH AVE
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City | NEW YORK
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State | NY
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Zip | 10128-0101
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Country | US
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Telephone | 212-874-3384
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Fax | 212-874-0031
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Provider Business Mailing Address
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Address Line | 1067 5TH AVE
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City | NEW YORK
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State | NY
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Zip | 10128-0101
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Country | US
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Telephone | 212-874-3384
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Fax | 212-874-0031
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Authorized Official
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Title or Position | OWNER
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Name | BLAIR S LEWIS
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Credential | MD
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Telephone | 212-874-3384
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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 | 156442
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License Number State | NY
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