Provider Demographics
NPI:1437662780
Name:PHYTIDES, MICHAEL PHILIP
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILIP
Last Name:PHYTIDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 FIGUREA AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-3239
Mailing Address - Country:US
Mailing Address - Phone:718-984-1806
Mailing Address - Fax:
Practice Address - Street 1:328 W SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-5638
Practice Address - Country:US
Practice Address - Phone:908-925-7519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021519-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant