Healthcare Provider Details

I. General information

NPI: 1144678954
Provider Name (Legal Business Name): STATEN ISLAND PHYSICIAN PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 06/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 CLOVE RD
STATEN ISLAND NY
10301-3627
US

IV. Provider business mailing address

441 9TH AVE 8TH FLOOR
NEW YORK NY
10001-1623
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-6440
  • Fax:
Mailing address:
  • Phone: 646-680-1580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH ZEITLIN
Title or Position: PRESIDENT
Credential: MD
Phone: 646-680-1580