1164594925 NPI number — TOTTENVILLE MEDICAL PAVILION, PLLC

Table of content: (NPI 1164594925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164594925 NPI number — TOTTENVILLE MEDICAL PAVILION, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOTTENVILLE MEDICAL PAVILION, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1164594925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7098 AMBOY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-356-5600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7098 AMBOY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-356-5600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CEKA
Authorized Official First Name:
BARI
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
718-356-5600

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  234924 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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