Provider Demographics
NPI:1396766499
Name:AM NEPHROLOGY CARE PC
Entity type:Organization
Organization Name:AM NEPHROLOGY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ALLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASLOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-769-4100
Mailing Address - Street 1:19 PERSHING STREET
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305
Mailing Address - Country:US
Mailing Address - Phone:917-981-1565
Mailing Address - Fax:
Practice Address - Street 1:1230 NEPTUNE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-2903
Practice Address - Country:US
Practice Address - Phone:718-615-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216703207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWDW011Medicare PIN