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NPI Code Detail

MEDICARE: GREGORY WILDE

MEDICARE: GREGORY WILDE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0202XDiagnostic Radiology Physician2514871NY

General Provider Information

NPI Number : 1023144177
Entity Type Code : Individual
Provider Name (Legal Business Name) : GREGORY WILDE
Provider Business Mailing Address
First Line : 401 E 80TH ST
Second Line : APT 32A
City : NEW YORK
State : NY
Zip : 10075-0655
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 61 E 77TH ST
Second Line : LENOX HILL RADIOLOGY
City : NEW YORK
State : NY
Zip : 10075-1817
Country : US
Telephone Number : 212-772-3111
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/25/2007
Last Update Date : 06/15/2021

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