1578550596 NPI number — MR. MARINO A POLISENO DO

Table of content: MR. MARINO A POLISENO DO (NPI 1578550596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578550596 NPI number — MR. MARINO A POLISENO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLISENO
Provider First Name:
MARINO
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1578550596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1050 CLOVE RD
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:
10301-3627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-680-2888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 CLOVE RD
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:
10301-3627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-442-4300
Provider Business Practice Location Address Fax Number:
718-816-8369
Provider Enumeration Date:
10/04/2005

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: 207V00000X , with the licence number:  225825 , 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: 7166589 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02590985 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0297012 . This is a "GHI" identifier . This identifiers is of the category "OTHER".




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