Provider Demographics
NPI:1760672620
Name:SILVER LAKE MEDICAL PLLC
Entity Type:Organization
Organization Name:SILVER LAKE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKOVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-556-3900
Mailing Address - Street 1:59 REVERE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3415
Mailing Address - Country:US
Mailing Address - Phone:718-556-3900
Mailing Address - Fax:718-273-3592
Practice Address - Street 1:59 REVERE ST
Practice Address - Street 2:SUITE A
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3415
Practice Address - Country:US
Practice Address - Phone:718-556-3900
Practice Address - Fax:718-273-3592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164175207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty