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General NPI Number Information
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NPI Number | 1104142082
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Entity Type | Organization
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Legal Business Name | STATEN ISLAND MEDICAL PRACTICE, P.C.
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Dates
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Enumeration Date | 04/16/2010
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Last Update Date | 04/16/2010
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Provider Practice Location Address
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Address Line | 5405 HYLAN BLVD
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City | STATEN ISLAND
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State | NY
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Zip | 10312-5241
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Country | US
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Telephone | 718-948-5475
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Fax | 718-948-5479
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Provider Business Mailing Address
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Address Line | 5405 HYLAN BLVD
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City | STATEN ISLAND
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State | NY
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Zip | 10312-5241
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Country | US
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Telephone | 718-948-5475
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Fax | 718-948-5479
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Authorized Official
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Title or Position | PHYSICIANS' ASSISTANT
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Name | MR. LEONARD J MARCHETTA
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Credential | RPA
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Telephone | 718-948-5475
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 191751
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License Number State | NY
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