Provider Demographics
NPI:1346444734
Name:GLENDALE FAMILY MEDICINE,PC
Entity Type:Organization
Organization Name:GLENDALE FAMILY MEDICINE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01220Medicare ID - Type Unspecified