Healthcare Provider Details

I. General information

NPI: 1982682001
Provider Name (Legal Business Name): STATEN ISLAND NEPHROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1366 VICTORY BLVD
STATEN ISLAND NY
10301-3907
US

IV. Provider business mailing address

1366 VICTORY BLVD
STATEN ISLAND NY
10301-3907
US

V. Phone/Fax

Practice location:
  • Phone: 718-727-3402
  • Fax: 718-727-3402
Mailing address:
  • Phone: 718-727-3402
  • Fax: 718-727-3402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02544181
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: MR. EUGENE PETRA
Title or Position: OWNER
Credential: MD
Phone: 718-273-3400