Healthcare Provider Details

I. General information

NPI: 1205127669
Provider Name (Legal Business Name): TARGEE STREET INTERNAL MEDICINE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 RALPH PL SUITE 317B
STATEN ISLAND NY
10304-4401
US

IV. Provider business mailing address

11 RALPH PL SUITE 317B
STATEN ISLAND NY
10304-4401
US

V. Phone/Fax

Practice location:
  • Phone: 718-447-4023
  • Fax: 718-273-2025
Mailing address:
  • Phone: 718-447-4023
  • Fax: 718-273-2025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAULINO V ALBANO
Title or Position: OWNER
Credential: MD
Phone: 718-447-4023