Provider Demographics
NPI:1881846962
Name:HOLY TRINITY MEDICAL, PLLC.
Entity Type:Organization
Organization Name:HOLY TRINITY MEDICAL, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NAGEH
Authorized Official - Middle Name:AYOOB
Authorized Official - Last Name:GARAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-447-1431
Mailing Address - Street 1:1376 CLOVE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-4303
Mailing Address - Country:US
Mailing Address - Phone:718-447-1431
Mailing Address - Fax:718-447-2754
Practice Address - Street 1:1376 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-4303
Practice Address - Country:US
Practice Address - Phone:718-447-1431
Practice Address - Fax:718-447-2754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237281261QH0100X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03025330Medicaid
NY03025330Medicaid