Provider Demographics
NPI:1639236854
Name:GLENRIDGE MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:GLENRIDGE MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPAK
Authorized Official - Middle Name:
Authorized Official - Last Name:SETIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-821-1222
Mailing Address - Street 1:385 SENECA AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1340
Mailing Address - Country:US
Mailing Address - Phone:718-821-1222
Mailing Address - Fax:
Practice Address - Street 1:385 SENECA AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1340
Practice Address - Country:US
Practice Address - Phone:718-821-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132693207R00000X
NY231211207R00000X
NY218001207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02396716Medicaid
NYWAC691Medicare ID - Type Unspecified