Healthcare Provider Details

I. General information

NPI: 1669888277
Provider Name (Legal Business Name): STATEN ISLAND MEDICAL OF NEW YORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 HYLAN BLVD
STATEN ISLAND NY
10306
US

IV. Provider business mailing address

1975 HYLAN BLVD
STATEN ISLAND NY
10306-3523
US

V. Phone/Fax

Practice location:
  • Phone: 186-909-5917
  • Fax: 224-235-4652
Mailing address:
  • Phone: 718-301-1100
  • Fax: 888-979-6720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: FLORA KATSNELSON
Title or Position: OWNER
Credential: MD
Phone: 847-257-1244