Healthcare Provider Details

I. General information

NPI: 1386813624
Provider Name (Legal Business Name): UNIVERSITY PHYSICIANS GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 ROSE AVE
STATEN ISLAND NY
10306-2246
US

IV. Provider business mailing address

65 ROSE AVENUE
STATEN ISLAND NY
10306-2246
US

V. Phone/Fax

Practice location:
  • Phone: 718-979-9333
  • Fax: 718-980-0408
Mailing address:
  • Phone: 718-979-9333
  • Fax: 718-980-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN005325
License Number StateNY

VIII. Authorized Official

Name: DR. THEODORE STRANGE
Title or Position: SECRETARY/TREASURER
Credential: MD
Phone: 718-226-1000