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General NPI Number Information
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NPI Number | 1861561441
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Entity Type | Organization
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Legal Business Name | S. ADIMOOLAM, PHYSICIAN, PC
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 08/18/2008
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Provider Practice Location Address
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Address Line | 1756 RICHMOND AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10314-3902
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Country | US
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Telephone | 718-494-3383
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Fax | 718-494-1705
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Provider Business Mailing Address
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Address Line | 1756 RICHMOND AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10314-3902
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Country | US
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Telephone | 718-494-3383
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Fax | 718-494-1705
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DEBRA PRUCHA
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Credential |
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Telephone | 718-494-4934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | NYS121313
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License Number State | NY
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