Provider Demographics
NPI:1679293443
Name:CCMMA CA PC
Entity type:Organization
Organization Name:CCMMA CA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LADUCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-702-2711
Mailing Address - Street 1:224 W 18TH ST APT 8A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-4558
Mailing Address - Country:US
Mailing Address - Phone:914-523-2189
Mailing Address - Fax:
Practice Address - Street 1:2 PARK AVE STE 2039
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5675
Practice Address - Country:US
Practice Address - Phone:845-702-2711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-31
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty