Provider Demographics
NPI:1124040530
Name:WEINER, KEVIN HARRIS (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:HARRIS
Last Name:WEINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3206
Mailing Address - Country:US
Mailing Address - Phone:718-442-4422
Mailing Address - Fax:718-556-3025
Practice Address - Street 1:262 NELSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-3206
Practice Address - Country:US
Practice Address - Phone:718-442-4422
Practice Address - Fax:718-556-3025
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2021652081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1856625OtherUHC
NY2700601OtherGHI
NY8U0471OtherBLUE SHIELD
NY5128695OtherAETNA PPO
NY2125718OtherAETNA HMO
NYP1101731OtherOXFORD
NY4C7484OtherHEALTHNET
NY8U0471OtherBLUE SHIELD
NYG82848Medicare UPIN