Provider Demographics
NPI:1871790071
Name:SPORTS & ORTHOPEDIC SURGERY OF NEW YORK, PLLC
Entity type:Organization
Organization Name:SPORTS & ORTHOPEDIC SURGERY OF NEW YORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:FERNANDEZ-MADRID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-254-0946
Mailing Address - Street 1:PO BOX 6402
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14851-6402
Mailing Address - Country:US
Mailing Address - Phone:212-254-0946
Mailing Address - Fax:212-254-0956
Practice Address - Street 1:205 E 16TH ST
Practice Address - Street 2:SUITE M1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3746
Practice Address - Country:US
Practice Address - Phone:212-254-0946
Practice Address - Fax:212-254-0956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217407174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWZT3V1Medicare PIN
NYH34192Medicare UPIN