Provider Demographics
NPI:1972869675
Name:PREMIUM MEDICAL OF NY,PC
Entity Type:Organization
Organization Name:PREMIUM MEDICAL OF NY,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGIOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-445-1223
Mailing Address - Street 1:14709 ELM AVE
Mailing Address - Street 2:SUITE B1
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-1705
Mailing Address - Country:US
Mailing Address - Phone:718-445-1223
Mailing Address - Fax:718-445-1539
Practice Address - Street 1:14709 ELM AVE
Practice Address - Street 2:SUITE B1
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1705
Practice Address - Country:US
Practice Address - Phone:718-445-1223
Practice Address - Fax:718-445-1539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193788207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty