1679647465 NPI number — DR. THOMAS N KOUTELOS INTERNAL MEDICINE

Table of content: DR. THOMAS N KOUTELOS INTERNAL MEDICINE (NPI 1679647465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679647465 NPI number — DR. THOMAS N KOUTELOS INTERNAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOUTELOS
Provider First Name:
THOMAS
Provider Middle Name:
N
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
INTERNAL MEDICINE
Provider Gender Code:
M

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:
1679647465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 PLAZA ST W STE 1F
Provider Second Line Business Mailing Address:
421 78TH STREET BROOKLYN NY 11209
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11217-3942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-622-1025
Provider Business Mailing Address Fax Number:
718-622-0915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 PLAZA ST W STE 1F
Provider Second Line Business Practice Location Address:
421 78TH STREET BROOKLYN NY 11209
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11217-3942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-622-1025
Provider Business Practice Location Address Fax Number:
718-622-0915
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  19052 1 , 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: 01366774 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113416490 . This is a "MAGNACARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: IC7375 . This is a "ACS HEALTHNET OF NE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P809058 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10L46 . This is a "EMPIRE BC-BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 113416490 . This is a "1199" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 113416490 . This is a "PHS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 190521 . This is a "HIP OF NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2023469 . This is a "AETNA HMO PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 113416490 . This is a "UNITED EMPIRE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5699985 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6638812006 . This is a "CIGNA PPO HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 33D0709729 . This is a "CLEAR#" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 11 0240756 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 113416490 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 113416490 . This is a "MULTI PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 113416490 . This is a "OTHER UNION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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