MEDICARE: STATEN ISLAND PHYSICIAN PRACTICE PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207N00000X	Dermatology Physician
2	207P00000X	Emergency Medicine Physician
3	207Q00000X	Family Medicine Physician
4	207RG0300X	Geriatric Medicine (Internal Medicine) Physician
5	207RH0003X	Hematology & Oncology Physician
6	207W00000X	Ophthalmology Physician
7	208000000X	Pediatrics Physician
8	2085R0202X	Diagnostic Radiology Physician
9	208600000X	Surgery Physician
10	208800000X	Urology Physician
11	207ND0101X	MOHS-Micrographic Surgery Physician
12	207NS0135X	Procedural Dermatology Physician
13	207NP0225X	Pediatric Dermatology Physician
14	207ND0900X	Dermatopathology Physician
15	207R00000X	Internal Medicine Physician

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	:	1568413169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATEN ISLAND PHYSICIAN PRACTICE PC

Provider Business Mailing Address
First Line	:	441 9TH AVE
Second Line	:	9TH FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10001-1623
Country	:	US
Telephone Number	:	646-680-2894
Fax Number	:

Provider Business Practice Location Address
First Line	:	441 9TH AVE
Second Line	:	9TH FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10001-1623
Country	:	US
Telephone Number	:	646-680-2894
Fax Number	:

Authorized Official
Title or Position	:	AVP - CREDENTIALING
Name	:	MARLENA SIMPSON
Credential	:	CPMSM
Telephone Number	:	646-680-2894

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	12/01/2015

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Directions to “STATEN ISLAND PHYSICIAN PRACTICE PC ” Practice Location

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