=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700201449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRE STREET SURGERY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2014
-----------------------------------------------------
Last Update Date | 03/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 139 CENTRE ST STE 609
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10013-4556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-431-4309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 139 CENTRE ST STE 609
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10013-4556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-431-4309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. ANTHONY J NG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 212-431-4309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------