Provider Demographics
NPI:1053627109
Name:NASSAU MEDICAL PRACTICE, PC
Entity Type:Organization
Organization Name:NASSAU MEDICAL PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAITANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KADIYALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-679-0009
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548-0383
Mailing Address - Country:US
Mailing Address - Phone:212-679-0009
Mailing Address - Fax:
Practice Address - Street 1:270 DOUGHTY BLVD
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-1367
Practice Address - Country:US
Practice Address - Phone:212-679-0009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232151207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty