Provider Demographics
NPI:1477711976
Name:NICHOLAS TRIANTAFILLOU MD PC
Entity Type:Organization
Organization Name:NICHOLAS TRIANTAFILLOU MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-825-0221
Mailing Address - Street 1:21305 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2044
Mailing Address - Country:US
Mailing Address - Phone:718-224-1378
Mailing Address - Fax:718-224-1758
Practice Address - Street 1:21305 39TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2044
Practice Address - Country:US
Practice Address - Phone:718-224-1378
Practice Address - Fax:718-224-1758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199020207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G61121Medicare UPIN
29N041Medicare PIN
03966Medicare PIN