Provider Demographics
NPI:1700950326
Name:KINGSTON SURGICAL, PLLC
Entity Type:Organization
Organization Name:KINGSTON SURGICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KALYAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:VENKAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-338-3212
Mailing Address - Street 1:40 HURLEY AVE
Mailing Address - Street 2:SUITE 17
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3739
Mailing Address - Country:US
Mailing Address - Phone:845-338-3212
Mailing Address - Fax:845-339-0299
Practice Address - Street 1:40 HURLEY AVE
Practice Address - Street 2:SUITE 17
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3739
Practice Address - Country:US
Practice Address - Phone:845-338-3212
Practice Address - Fax:845-339-0299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136378-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00573331Medicaid
NY00573331Medicaid