Provider Demographics
NPI:1750544771
Name:KENNETH H PETERSEL MD PC
Entity type:Organization
Organization Name:KENNETH H PETERSEL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-794-1330
Mailing Address - Street 1:1617 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-2345
Mailing Address - Country:US
Mailing Address - Phone:516-794-1330
Mailing Address - Fax:
Practice Address - Street 1:1617 FRONT ST
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-2345
Practice Address - Country:US
Practice Address - Phone:516-794-1330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW38011Medicare PIN