Healthcare Provider Details

I. General information

NPI: 1821093444
Provider Name (Legal Business Name): GEORGE A. PETROSSIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 OLD NORTHERN BLVD
ROSLYN NY
11576-2252
US

IV. Provider business mailing address

PO BOX 95000-6600
PHILADELPHIA PA
19195-6600
US

V. Phone/Fax

Practice location:
  • Phone: 516-484-6777
  • Fax: 516-484-0037
Mailing address:
  • Phone: 631-465-6297
  • Fax: 631-465-6524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number159502-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: