=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821443805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER EASTSIDE INTERNAL MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2016
-----------------------------------------------------
Last Update Date | 04/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 E 86TH ST SUITE 202A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10028-3003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-249-1627
-----------------------------------------------------
Fax | 212-249-1640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 E 86TH ST SUITE 202A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10028-3003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-249-1627
-----------------------------------------------------
Fax | 212-249-1640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LEON SCRIMMAGER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 212-249-1627
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 184535
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------