Provider Demographics
NPI:1477694800
Name:STATEN ISLAND INTERNAL MEDICINE ASSOC PC
Entity Type:Organization
Organization Name:STATEN ISLAND INTERNAL MEDICINE ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEINERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-448-4448
Mailing Address - Street 1:1478 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301
Mailing Address - Country:US
Mailing Address - Phone:718-448-4448
Mailing Address - Fax:718-442-5691
Practice Address - Street 1:1478 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301
Practice Address - Country:US
Practice Address - Phone:718-448-4448
Practice Address - Fax:718-442-5691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP120OtherOXFORD
OP120OtherOXFORD
OP120OtherOXFORD
30A011Medicare ID - Type Unspecified