Provider Demographics
NPI:1275978967
Name:GLENDALE FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:GLENDALE FAMILY MEDICINE, PC
Other - Org Name:GLENDALE FAMILY MEDICINE WALK-IN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SEBASTIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-386-8300
Mailing Address - Street 1:7801 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7439
Mailing Address - Country:US
Mailing Address - Phone:718-386-8300
Mailing Address - Fax:718-386-0437
Practice Address - Street 1:7801 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7439
Practice Address - Country:US
Practice Address - Phone:718-386-8300
Practice Address - Fax:718-386-0437
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLENDALE FAMILY MEDICINE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-08
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168147261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01220Medicare PIN
NYD92080Medicare UPIN