Provider Demographics
NPI: | 1467436303 |
---|---|
Name: | KITSIS, PAUL (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | PAUL |
Middle Name: | |
Last Name: | KITSIS |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1 EDGEWATER ST |
Mailing Address - Street 2: | SUITE 723 |
Mailing Address - City: | STATEN ISLAND |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10305-4900 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 718-226-1013 |
Mailing Address - Fax: | 718-226-1039 |
Practice Address - Street 1: | 475 SEAVIEW AVE |
Practice Address - Street 2: | |
Practice Address - City: | STATEN ISLAND |
Practice Address - State: | NY |
Practice Address - Zip Code: | 10305-3436 |
Practice Address - Country: | US |
Practice Address - Phone: | 718-226-9488 |
Practice Address - Fax: | 718-226-8132 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-12-05 |
Last Update Date: | 2010-05-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 224342 | 207RC0200X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 02390783 | Medicaid | |
NY | 138AH1 | Medicare ID - Type Unspecified | |
NY | 02390783 | Medicaid |