Provider Demographics
NPI:1922214600
Name:PRIDE MEDICAL, PLLC
Entity Type:Organization
Organization Name:PRIDE MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PUNYADECH
Authorized Official - Middle Name:
Authorized Official - Last Name:PHOTANGTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-656-2951
Mailing Address - Street 1:3875 BROADWAY
Mailing Address - Street 2:UNIT B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1567
Mailing Address - Country:US
Mailing Address - Phone:917-656-2951
Mailing Address - Fax:
Practice Address - Street 1:3875 BROADWAY
Practice Address - Street 2:UNIT B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1567
Practice Address - Country:US
Practice Address - Phone:917-656-2951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1083700926OtherNPI
NY1083700926OtherNPI
NYG99235Medicare UPIN