=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235917691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDINAL NY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2023
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8808 ROCKAWAY BEACH BLVD UNIT 209
-----------------------------------------------------
City | ROCKAWAY BCH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11693-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-254-0600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8808 ROCKAWAY BEACH BLVD UNIT 209
-----------------------------------------------------
City | ROCKAWAY BCH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11693-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. ARCHIL ARJEVANIDZE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-220-1152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------