Provider Demographics
NPI:1023369873
Name:GAMMA CHIROPRACTIC PC
Entity Type:Organization
Organization Name:GAMMA CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZUROVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:718-998-3020
Mailing Address - Street 1:1332 FOREST AVE
Mailing Address - Street 2:STATEN ISLAND
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2043
Mailing Address - Country:US
Mailing Address - Phone:718-442-8813
Mailing Address - Fax:718-876-0158
Practice Address - Street 1:1332 FOREST AVE
Practice Address - Street 2:STATEN ISLAND
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2043
Practice Address - Country:US
Practice Address - Phone:718-442-8813
Practice Address - Fax:718-876-0158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009550111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009550OtherLICENSE
NYX1D031Medicare PIN