33D2157722 CLIA NUMBER - MOTT HAVEN PROFESSIONAL MEDICAL OF NEW YORK LLC

Laboratory Demographics

CLIA Number: 33D2157722

Facility Name: MOTT HAVEN PROFESSIONAL MEDICAL OF NEW YORK LLC

Facility Address:
384 E 149TH STREET - STE 201A
BRONX, NY
ZIP 10455
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Facility Phone Number: 847 257-1237

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1457873234

Taxonomy: 2086S0129X - Surgery
A surgeon with expertise in the management of surgical disorders of the blood vessels, excluding the intracranial vessels or the heart.

CLIA Record

Field Name	Field Value
CLIA Number	33D2157722
LAB Type	Physician Office
Facility Name	MOTT HAVEN PROFESSIONAL MEDICAL OF NEW YORK LLC
Street	384 E 149TH STREET - STE 201A
City	BRONX
State	NY
ZIP	10455
Phone	847 257-1237
CertificateType	4
CertificateEffectiveDate	11/18/2023
CertificateExpirationDate	11/17/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024