1699900332 NPI number — S&G MEDICAL OFFICE, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699900332 NPI number — S&G MEDICAL OFFICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S&G MEDICAL OFFICE, 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:
1699900332
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 EAST BROADWAY
Provider Second Line Business Mailing Address:
SUITE 603
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-233-2078
Provider Business Mailing Address Fax Number:
212-233-2079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 EAST BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 603
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-233-2078
Provider Business Practice Location Address Fax Number:
212-233-2079
Provider Enumeration Date:
05/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SONG
Authorized Official First Name:
MIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
212-233-2078

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  214737 , 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: 01991455 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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