Provider Demographics
NPI:1053436600
Name:CONVENIENT CARE MEDICAL
Entity type:Organization
Organization Name:CONVENIENT CARE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-248-5556
Mailing Address - Street 1:48 ROUTE 6 & MAHOPAC AVE
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598
Mailing Address - Country:US
Mailing Address - Phone:914-248-5556
Mailing Address - Fax:914-248-4091
Practice Address - Street 1:48 RTE 6 & MAHOPAC AVE
Practice Address - Street 2:
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598
Practice Address - Country:US
Practice Address - Phone:914-248-5556
Practice Address - Fax:914-248-4091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2007-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151663-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC10721Medicare UPIN
CG4821Medicare PIN
W33811Medicare PIN