Provider Demographics
NPI:1609222173
Name:SUPPORTIVE MEDICAL PC
Entity type:Organization
Organization Name:SUPPORTIVE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-681-8222
Mailing Address - Street 1:181 MALCOLM X BLVD
Mailing Address - Street 2:UNIT 2
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-1364
Mailing Address - Country:US
Mailing Address - Phone:646-883-2273
Mailing Address - Fax:
Practice Address - Street 1:181 MALCOLM X BLVD
Practice Address - Street 2:UNIT 2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1364
Practice Address - Country:US
Practice Address - Phone:646-883-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative MedicineGroup - Single Specialty