Provider Demographics
NPI:1700047289
Name:CLERISY MEDICAL, PC
Entity Type:Organization
Organization Name:CLERISY MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GULAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-840-7142
Mailing Address - Street 1:114 TALLEY RD S
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2598
Mailing Address - Country:US
Mailing Address - Phone:718-421-2131
Mailing Address - Fax:718-421-2130
Practice Address - Street 1:446 MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2212
Practice Address - Country:US
Practice Address - Phone:718-972-4200
Practice Address - Fax:718-972-6861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228737174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02426433Medicaid
NY02426433Medicaid