Provider Demographics
NPI:1376747378
Name:GENNADIY KVETNY PHYSICIAN, PC
Entity Type:Organization
Organization Name:GENNADIY KVETNY PHYSICIAN, PC
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GENNADIY
Authorized Official - Middle Name:
Authorized Official - Last Name:KVETNY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-894-4200
Mailing Address - Street 1:7554 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-2639
Mailing Address - Country:US
Mailing Address - Phone:718-894-4200
Mailing Address - Fax:718-894-3900
Practice Address - Street 1:7554 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-2639
Practice Address - Country:US
Practice Address - Phone:718-894-4200
Practice Address - Fax:718-894-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208977207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01897043Medicaid
NY16709Medicare ID - Type Unspecified
NY01897043Medicaid