Provider Demographics
NPI:1699248542
Name:GREAT WALL MEDICAL, P.C.
Entity type:Organization
Organization Name:GREAT WALL MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:JOON
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-481-1118
Mailing Address - Street 1:201E 28TH STREET
Mailing Address - Street 2:SUITE #1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:212-481-1118
Mailing Address - Fax:212-448-1049
Practice Address - Street 1:201E 28TH STREET
Practice Address - Street 2:SUITE #1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-481-1118
Practice Address - Fax:212-448-1049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02907826Medicaid