=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164546610
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTHALMOLOGY ASSOC OF STATIEN ISLAND DBA BRIDGE OPTICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 03/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1460 VICTORY BLVD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-876-5966
-----------------------------------------------------
Fax | 718-876-6097
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1460 VICTORY BLVD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-876-5966
-----------------------------------------------------
Fax | 718-876-6097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DENNIS J. GORMLEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-447-0022
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------