Healthcare Provider Details

I. General information

NPI: 1124040530
Provider Name (Legal Business Name): KEVIN HARRIS WEINER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 NELSON AVE
STATEN ISLAND NY
10308-3206
US

IV. Provider business mailing address

262 NELSON AVE
STATEN ISLAND NY
10308-3206
US

V. Phone/Fax

Practice location:
  • Phone: 718-442-4422
  • Fax: 718-556-3025
Mailing address:
  • Phone: 718-442-4422
  • Fax: 718-556-3025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number202165
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: