Healthcare Provider Details

I. General information

NPI: 1609276534
Provider Name (Legal Business Name): ADEM MARTIN GERAGHTY NPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4904 19TH AVE
ASTORIA NY
11105-1002
US

IV. Provider business mailing address

4904 19TH AVE
ASTORIA NY
11105-1002
US

V. Phone/Fax

Practice location:
  • Phone: 347-774-8000
  • Fax:
Mailing address:
  • Phone: 347-774-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number401769
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number596486
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: