MEDICARE: MR. SIMON LICHTIGER M.D

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
1	207R00000X	Internal Medicine Physician	146902	NY
2	174400000X	Specialist	146902	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NS4196	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1053409847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SIMON LICHTIGER M.D

Provider Business Mailing Address
First Line	:	630 W 168TH ST
Second Line	:	BOX 4
City	:	NEW YORK
State	:	NY
Zip	:	10032-3725
Country	:	US
Telephone Number	:	212-342-5155
Fax Number	:	212-722-4703

Provider Business Practice Location Address
First Line	:	12 EAST 86 ST.
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10028-6849
Country	:	US
Telephone Number	:	212-831-4900
Fax Number	:	212-722-4703

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	09/04/2014

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Directions to “ MR. SIMON LICHTIGER M.D” Practice Location

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