Healthcare Provider Details

I. General information

NPI: 1760672620
Provider Name (Legal Business Name): SILVER LAKE MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 REVERE ST SUITE A
STATEN ISLAND NY
10301-3415
US

IV. Provider business mailing address

59 REVERE ST SUITE A
STATEN ISLAND NY
10301-3415
US

V. Phone/Fax

Practice location:
  • Phone: 718-556-3900
  • Fax: 718-273-3592
Mailing address:
  • Phone: 718-556-3900
  • Fax: 718-273-3592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number164175
License Number StateNY

VIII. Authorized Official

Name: KENNETH PICKOVER
Title or Position: MEMBER
Credential: M.D.
Phone: 718-556-3900