Provider Demographics
NPI:1598753253
Name:ISLAND NEPHROLOGY SERVICES, P.C.
Entity Type:Organization
Organization Name:ISLAND NEPHROLOGY SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-876-6220
Mailing Address - Street 1:97 NEW DORP LANE
Mailing Address - Street 2:SUITE A
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2347
Mailing Address - Country:US
Mailing Address - Phone:718-876-6220
Mailing Address - Fax:718-876-5969
Practice Address - Street 1:470 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3401
Practice Address - Country:US
Practice Address - Phone:718-987-5940
Practice Address - Fax:718-667-9708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01619025Medicaid
NY03189AMedicare PIN
NY01619025Medicaid
W1U961Medicare ID - Type Unspecified