Basic Information
| Provider Information | |||||||||
| NPI: | 1477570372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERSICH | ||||||||
| FirstName: | GIANNI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2856A 41ST ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111033301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187770360 | ||||||||
| FaxNumber: | 7187773180 | ||||||||
| Practice Location | |||||||||
| Address1: | 2856 41ST ST | ||||||||
| Address2: | SUITE2A | ||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111033302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187770360 | ||||||||
| FaxNumber: | 7187773180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N004789 | NY | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0131X | N004789 | NY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01360874 | 05 | NY | MEDICAID |