Provider Demographics
NPI:1245439215
Name:DEROSA ORTHOPEDIC SERVICES, PC
Entity type:Organization
Organization Name:DEROSA ORTHOPEDIC SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-204-0414
Mailing Address - Street 1:1101 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4892
Mailing Address - Country:US
Mailing Address - Phone:718-204-0414
Mailing Address - Fax:
Practice Address - Street 1:4701 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-1600
Practice Address - Country:US
Practice Address - Phone:718-784-4747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129321207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00402355Medicaid
NY315271Medicare PIN
NY00402355Medicaid
NY315273Medicare PIN