1598753253 NPI number — ISLAND NEPHROLOGY SERVICES, PC

Table of content: (NPI 1598753253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598753253 NPI number — ISLAND NEPHROLOGY SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND NEPHROLOGY SERVICES, PC
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:
1598753253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
97 NEW DORP LN STE A
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:
10306-2364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-876-6220
Provider Business Mailing Address Fax Number:
718-876-5969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
470 SEAVIEW AVE
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:
10305-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-987-5940
Provider Business Practice Location Address Fax Number:
718-667-9708
Provider Enumeration Date:
10/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GUTERMAN
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
718-876-6220

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , 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: 02433681 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02514845 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02882497 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05081681 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00398958 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00955082 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02372145 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05961591 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00790556 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01619025 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03331142 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01905724 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00848884 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03328356 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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