Provider Demographics
NPI:1972693315
Name:TRISTATE MEDICAL CARE PC
Entity Type:Organization
Organization Name:TRISTATE MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD FACP FACC
Authorized Official - Prefix:DR
Authorized Official - First Name:SHASHIBALA
Authorized Official - Middle Name:
Authorized Official - Last Name:SONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-236-4444
Mailing Address - Street 1:8200 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214
Mailing Address - Country:US
Mailing Address - Phone:718-236-6644
Mailing Address - Fax:718-236-9080
Practice Address - Street 1:3615 AVE S
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234
Practice Address - Country:US
Practice Address - Phone:718-336-2110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128754207R00000X, 207RC0000X, 261QP2300X
NJ25MA06036700261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWER141Medicare PIN