MEDICARE: STATEN ISLAND GSC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1033815915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATEN ISLAND GSC LLC

Provider Business Mailing Address
First Line	:	2043 RICHMOND AVE FL 1
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3964
Country	:	US
Telephone Number	:	718-975-7574
Fax Number	:

Provider Business Practice Location Address
First Line	:	2043 RICHMOND AVE FL 1
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3964
Country	:	US
Telephone Number	:	718-975-7574
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. ALEXANDER BRUN
Credential	:	MD
Telephone Number	:	718-450-4870

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	02/02/2023

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