Provider Demographics
NPI:1821093444
Name:PETROSSIAN, GEORGE A (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:A
Last Name:PETROSSIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95000-6600
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-6600
Mailing Address - Country:US
Mailing Address - Phone:631-465-6297
Mailing Address - Fax:631-465-6524
Practice Address - Street 1:1405 OLD NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-2252
Practice Address - Country:US
Practice Address - Phone:516-484-6777
Practice Address - Fax:516-484-0037
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159502-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1047935OtherAETNA USHC-HMO
NY2198834OtherGHI/FLEX SELECT/PPO
NY85F031OtherBCBS - PROVIDER I.D.
NY159502 AND 28446POtherHIP - PROVIDER I.D.
NY4221943OtherAETNA USHC - NON HMO
NYZS068OtherOXFORD - PROVIDER I.D.
NY000000067277OtherGHI/HMO PROVIDER I.D.
NY1210804OtherUNITED HEALTHCARE
NY2C8634OtherHEALTHNET - PROVIDER I.D.
NY05405GOtherGHI MEDICARE (QUEENS)
NY19684OtherVYTRA - PROVIDER I.D.
NY01848737Medicaid
NY3986056009OtherCIGNA - PROVIDER I.D.
NY4221943OtherAETNA USHC - NON HMO
NYE58263Medicare UPIN