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General NPI Number Information
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NPI Number | 1083992317
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Entity Type | Organization
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Legal Business Name | PREMIER NEPHROLOGY SERVICES PC
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Dates
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Enumeration Date | 08/03/2011
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Last Update Date | 03/15/2012
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Provider Practice Location Address
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Address Line | 723 REMSEN AVE
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City | BROOKLYN
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State | NY
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Zip | 11236-1227
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Country | US
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Telephone | 718-345-9106
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Fax | 718-261-1336
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Provider Business Mailing Address
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Address Line | 723 REMSEN AVE
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City | BROOKLYN
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State | NY
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Zip | 11236-1227
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Country | US
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Telephone | 718-345-9106
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Fax | 718-261-1336
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. STAFFORD DESMOND JOHN
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Credential |
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Telephone | 718-345-9106
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 202469
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License Number State | NY
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