Healthcare Provider Details

I. General information

NPI: 1275564841
Provider Name (Legal Business Name): STATEN ISLAND MEDICAL INTENSIVIST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/11/2025
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 ST SUITE 723
STATEN ISLAND NY
10305-4900
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-1673
  • Fax: 718-226-8834
Mailing address:
  • Phone: 718-226-1013
  • Fax: 718-226-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNY

VIII. Authorized Official

Name: DR. THEODORE MANIATIS
Title or Position: DIRECTOR
Credential: MD
Phone: 718-226-8836