Healthcare Provider Details

I. General information

NPI: 1457376022
Provider Name (Legal Business Name): EMERGENCY MEDICINE SERVICES OF STATEN ISLAND, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 04/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

1 EDGEWATER STREET 6TH FLOOR
STATEN ISLAND NY
10305
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-9158
  • Fax:
Mailing address:
  • Phone: 718-226-1013
  • Fax: 718-226-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name: DR. BRAHIM ARDOLIC
Title or Position: DIRECTOR
Credential: MD
Phone: 718-226-9158