MEDICARE: SOUTH BEACH PC

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	302R00000X	Health Maintenance Organization

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295927036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BEACH PC

Provider Business Mailing Address
First Line	:	44 HOLLAND AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12229-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 SEAVIEW AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10305-3409
Country	:	US
Telephone Number	:	718-667-2300
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR, FINANCE
Name	:	ROBERT PUCCIO
Credential	:
Telephone Number	:	518-473-0795

Provider Enumeration Date	:	08/15/2007
Last Update Date	:	08/28/2014

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