Provider Demographics
NPI:1326302803
Name:STATEN ISLAND MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:STATEN ISLAND MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSEMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-857-4011
Mailing Address - Street 1:PO BOX 581
Mailing Address - Street 2:
Mailing Address - City:SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-0581
Mailing Address - Country:US
Mailing Address - Phone:201-857-4011
Mailing Address - Fax:
Practice Address - Street 1:2071 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1612
Practice Address - Country:US
Practice Address - Phone:718-391-0303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4431261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4431OtherAAAASF