Provider Demographics
NPI:1750001350
Name:PREVENTATIVE HEALTHCARE MEDICAL SERVICES OF NEW YORK, PC
Entity type:Organization
Organization Name:PREVENTATIVE HEALTHCARE MEDICAL SERVICES OF NEW YORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:CHASE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-994-1770
Mailing Address - Street 1:122 E 42ND ST FL 18
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10168-1899
Mailing Address - Country:US
Mailing Address - Phone:917-994-1770
Mailing Address - Fax:
Practice Address - Street 1:122 E 42ND ST FL 18
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10168-1899
Practice Address - Country:US
Practice Address - Phone:917-994-1770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty