1700950326 NPI number — KINGSTON SURGICAL, PLLC

Table of content: (NPI 1700950326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700950326 NPI number — KINGSTON SURGICAL, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGSTON SURGICAL, PLLC
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:
1700950326
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 HURLEY AVE
Provider Second Line Business Mailing Address:
SUITE 17
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12401-3739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-338-3212
Provider Business Mailing Address Fax Number:
845-339-0299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 HURLEY AVE
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12401-3739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-338-3212
Provider Business Practice Location Address Fax Number:
845-339-0299
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VENKAT
Authorized Official First Name:
KALYAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
845-338-3212

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  136378-1 , 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: 00573331 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com