Provider Demographics
NPI:1982682001
Name:STATEN ISLAND NEPHROLOGY PC
Entity Type:Organization
Organization Name:STATEN ISLAND NEPHROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-273-3400
Mailing Address - Street 1:1366 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3907
Mailing Address - Country:US
Mailing Address - Phone:718-727-3402
Mailing Address - Fax:718-727-3402
Practice Address - Street 1:1366 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3907
Practice Address - Country:US
Practice Address - Phone:718-727-3402
Practice Address - Fax:718-727-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02544181Medicaid
NY02544181Medicaid