1306169263 NPI number — FAMILY GASTRO, P.C.

Table of content: (NPI 1306169263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306169263 NPI number — FAMILY GASTRO, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY GASTRO, P.C.
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306169263
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
254 BIRCHWOOD PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JERICHO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11753-2307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-833-4742
Provider Business Mailing Address Fax Number:
718-836-4629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9711 3RD AVE
Provider Second Line Business Practice Location Address:
BSMT LEVEL
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11209-7702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-833-4742
Provider Business Practice Location Address Fax Number:
718-836-4629
Provider Enumeration Date:
03/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ELDARAWY
Authorized Official First Name:
WAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
516-849-7515

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  245326 , 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)

  • Identifier: 03124774 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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