Provider Demographics
NPI:1194830265
Name:43RD ST FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:43RD ST FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DURGA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDINENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-392-2220
Mailing Address - Street 1:4543 43RD ST
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-2609
Mailing Address - Country:US
Mailing Address - Phone:718-392-2220
Mailing Address - Fax:
Practice Address - Street 1:4543 43RD ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2609
Practice Address - Country:US
Practice Address - Phone:718-392-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02462119Medicaid
NY07827Medicare PIN