Basic Information
| Provider Information | |||||||||
| NPI: | 1770747891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GIANNI PERSICH DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4207 30TH AVE | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111032910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187770360 | ||||||||
| FaxNumber: | 7187773180 | ||||||||
| Practice Location | |||||||||
| Address1: | 4207 30TH AVE | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111032910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187770360 | ||||||||
| FaxNumber: | 7187773180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 08/04/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PERSICH | ||||||||
| AuthorizedOfficialFirstName: | GIANNI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 7187770360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | N004789 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | P376490 | 01 | NY | OXFORD | OTHER | P52221 | 01 | NY | EMPIRE BLUE CROSS | OTHER |