Provider Demographics
NPI:1235413527
Name:BATH BEACH MEDICAL PC
Entity Type:Organization
Organization Name:BATH BEACH MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHITOOR
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOVINDARAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-836-3333
Mailing Address - Street 1:1551 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2313
Mailing Address - Country:US
Mailing Address - Phone:718-836-3333
Mailing Address - Fax:718-836-3334
Practice Address - Street 1:1551 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2313
Practice Address - Country:US
Practice Address - Phone:718-836-3333
Practice Address - Fax:718-836-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111292207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY571991Medicare PIN