Provider Demographics
NPI:1376628073
Name:TRISTATE PODIATRY P.C.
Entity Type:Organization
Organization Name:TRISTATE PODIATRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NACHUM
Authorized Official - Middle Name:
Authorized Official - Last Name:PELCOVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-239-8300
Mailing Address - Street 1:183 WILDACRE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1414
Mailing Address - Country:US
Mailing Address - Phone:516-239-8300
Mailing Address - Fax:516-371-9418
Practice Address - Street 1:183 WILDACRE AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1414
Practice Address - Country:US
Practice Address - Phone:516-239-8300
Practice Address - Fax:516-371-9418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003598-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00792609Medicaid
NJ9073205Medicaid
CT3071917Medicaid
NY00792609Medicaid
NY06862Medicare ID - Type UnspecifiedGHI
NYT51124Medicare UPIN
NJ9073205Medicaid
CTC03246Medicare PIN
NYP00195914Medicare ID - Type UnspecifiedRAILROAD
CT3071917Medicaid