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General NPI Number Information
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NPI Number | 1659676963
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Entity Type | Organization
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Legal Business Name | STATEN ISLAND MEDICAL PROFESSIONAL PC
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Dates
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Enumeration Date | 01/18/2011
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Last Update Date | 01/18/2011
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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 | 718-356-0207
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Fax |
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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 | 718-356-0207
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. EDWIN BARRY GORDON
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Credential | M.D
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Telephone | 718-356-0207
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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 | 097198
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License Number State | NY
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