| | Physician Last Name: | Fifty-eighth Street Medical |
| | Physician First Name: | P.C. |
| | Physician Middle Name: | |
| | Address: | C/O Robban Sica, M.D.
37 Lakewood Road
Trumbull, Connecticut 06611 |
| | License Number: | 199255 |
| | License Type: | |
| | Year of Birth: |
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| | Effective Date: | 01/17/2002 |
| | Action Description for DOH Webpage: | Revocation of certificate of incorporation |
| | Misconduct Description for DOH Webpage: | The corporation admitted to the charge of failing to comply with New York State Business Corporation Law Section 1503. |
| | License Limitations or Conditions for DOH Webpage: | |
| | Board Order: |
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