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General NPI Number Information
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NPI Number | 1417081795
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Entity Type | Individual
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Provider Name | PREM SRIVASTAVA MD
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Gender | Male
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 04/12/2010
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Provider Practice Location Address
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Address Line | 1 MAIN ST
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City | ROOSEVELT ISLAND
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State | NY
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Zip | 10044-0052
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Country | US
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Telephone | 212-318-4515
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Fax |
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Provider Business Mailing Address
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Address Line | 1703 N JERUSALEM RD
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City | EAST MEADOW
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State | NY
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Zip | 11554-4741
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Country | US
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Telephone | 516-565-9612
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 19269801
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License Number State | NY
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