Healthcare Provider Details

I. General information

NPI: 1033204391
Provider Name (Legal Business Name): USCG SECTOR NY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 DRUM RD RM D-113
STATEN ISLAND NY
10305-5001
US

IV. Provider business mailing address

438 USS IOWA CIR APT 5
STATEN ISLAND NY
10305-5059
US

V. Phone/Fax

Practice location:
  • Phone: 718-354-4414
  • Fax: 718-354-4415
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARA DEMERS
Title or Position: HEALTH SERVICES TECH. 2ND CLASS
Credential:
Phone: 718-354-4414