MEDICARE: S. ADIMOOLAM, PHYSICIAN, 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	174400000X	Specialist	NYS121313	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0019584	OTHER	NY	GROUP HEALTH INSURANCE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	OC1723	OTHER	NY	PHC
4	OS053	OTHER	NY	OXFORD HEALTH PLANS

General Provider Information

NPI Number	:	1861561441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S. ADIMOOLAM, PHYSICIAN, PC

Provider Business Mailing Address
First Line	:	1756 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3902
Country	:	US
Telephone Number	:	718-494-3383
Fax Number	:	718-494-1705

Provider Business Practice Location Address
First Line	:	1756 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3902
Country	:	US
Telephone Number	:	718-494-3383
Fax Number	:	718-494-1705

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. DEBRA PRUCHA
Credential	:
Telephone Number	:	718-494-4934

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	08/18/2008

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