Provider Demographics
NPI:1003138926
Name:AVENUE P MEDICAL SERVICES, PC
Entity Type:Organization
Organization Name:AVENUE P MEDICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTNIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-845-9255
Mailing Address - Street 1:214 AVENUE P
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-6573
Mailing Address - Country:US
Mailing Address - Phone:212-845-9255
Mailing Address - Fax:347-602-4674
Practice Address - Street 1:214 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-6573
Practice Address - Country:US
Practice Address - Phone:212-845-9255
Practice Address - Fax:347-602-4674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163630174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400033414Medicare PIN
NYA400033404Medicare PIN
NYA400033410Medicare PIN
NYA100033388Medicare PIN
NYA400033691Medicare PIN