Provider Demographics
NPI:1457085615
Name:SG MEDICAL PROFESSIONALS PC
Entity Type:Organization
Organization Name:SG MEDICAL PROFESSIONALS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-362-1405
Mailing Address - Street 1:612 CORPORATE WAY STE 2M
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2027
Mailing Address - Country:US
Mailing Address - Phone:718-362-1405
Mailing Address - Fax:718-414-1651
Practice Address - Street 1:260 CHRISTOPHER LN STE 102A
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1631
Practice Address - Country:US
Practice Address - Phone:718-362-1405
Practice Address - Fax:718-414-1651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty