Basic Information
| Provider Information | |||||||||
| NPI: | 1013149038 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAFFI BARSOUMIAN MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 DEVINE AVE | ||||||||
| Address2: | |||||||||
| City: | SYOSSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117913721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162871120 | ||||||||
| FaxNumber: | 5167949568 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 DEVINE AVE | ||||||||
| Address2: | |||||||||
| City: | SYOSSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117913721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162871120 | ||||||||
| FaxNumber: | 5167949568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2009 | ||||||||
| LastUpdateDate: | 08/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | RESTIVO | ||||||||
| AuthorizedOfficialFirstName: | PATTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5167944161 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 240858 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02935702 | 05 | NY | MEDICAID |