Basic Information
| Provider Information | |||||||||
| NPI: | 1316074909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. NICHOLAS GASTROENTEROLOGY P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 ST. NICHOLAS AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188210643 | ||||||||
| FaxNumber: | 7186284123 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 ST. NICHOLAS AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188210643 | ||||||||
| FaxNumber: | 7186284123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ARYA | ||||||||
| AuthorizedOfficialFirstName: | YASHPAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7188210643 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00210779 | 05 | NY | MEDICAID | 02743451 | 05 | NY | MEDICAID |