Healthcare Provider Details

I. General information

NPI: 1881846962
Provider Name (Legal Business Name): HOLY TRINITY MEDICAL, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1376 CLOVE RD
STATEN ISLAND NY
10301-4303
US

IV. Provider business mailing address

1376 CLOVE RD
STATEN ISLAND NY
10301-4303
US

V. Phone/Fax

Practice location:
  • Phone: 718-447-1431
  • Fax: 718-447-2754
Mailing address:
  • Phone: 718-447-1431
  • Fax: 718-447-2754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number237281
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number237281
License Number StateNY

VIII. Authorized Official

Name: DR. NAGEH AYOOB GARAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 718-447-1431