Basic Information
| Provider Information | |||||||||
| NPI: | 1770519290 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY MEDICINE PHYSICIANS OF STATEN ISLAND, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 BARD AVE | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103101664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188182055 | ||||||||
| FaxNumber: | 2123564608 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 BARD AVE | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103101664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188182055 | ||||||||
| FaxNumber: | 2123564608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ADRIAN | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7188182055 | ||||||||
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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 | 207P00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PP0204X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01511760 | 05 | NY | MEDICAID |