=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851917645
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON SHI SAMUEL XIE MD, MSC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2020
-----------------------------------------------------
Last Update Date | 05/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 177 FORT WASHINGTON AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-305-3090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 177 FORT WASHINGTON AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-305-3090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 2020018991
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 2022037479
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 327674
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------