Provider Demographics
NPI:1457376022
Name:EMERGENCY MEDICINE SERVICES OF STATEN ISLAND, PC
Entity type:Organization
Organization Name:EMERGENCY MEDICINE SERVICES OF STATEN ISLAND, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ARDOLIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-226-9158
Mailing Address - Street 1:1 EDGEWATER STREET
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305
Mailing Address - Country:US
Mailing Address - Phone:718-226-1013
Mailing Address - Fax:718-226-1039
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-9158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207PP0204X, 207P00000X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02244851Medicaid
NYCJ7965OtherRR MEDICARE #
NYCJ7965OtherRR MEDICARE #