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NPI Code Detail

MEDICARE: STATEN ISLAND NEPHROLOGY PC

MEDICARE: STATEN ISLAND NEPHROLOGY 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
1207RN0300XNephrology Physician

Other Identifiers

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

General Provider Information

NPI Number : 1982682001
Entity Type Code : Organization
Provider Name (Legal Business Name) : STATEN ISLAND NEPHROLOGY PC
Provider Business Mailing Address
First Line : 1366 VICTORY BLVD
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10301-3907
Country : US
Telephone Number : 718-727-3402
Fax Number : 718-727-3402
Provider Business Practice Location Address
First Line : 1366 VICTORY BLVD
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10301-3907
Country : US
Telephone Number : 718-727-3402
Fax Number : 718-727-3402
Authorized Official
Title or Position : OWNER
Name : MR. EUGENE PETRA
Credential : MD
Telephone Number : 718-273-3400
Provider Enumeration Date : 01/09/2006
Last Update Date : 02/08/2008

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Practice Fax: 718-727-3402

Directions to “STATEN ISLAND NEPHROLOGY PC ” Practice Location

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