Basic Information
| Provider Information | |||||||||
| NPI: | 1780895425 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATEN ISLAND PULMONARY ASSOC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 SEAVIEW AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103053400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189805700 | ||||||||
| FaxNumber: | 7819805499 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SEAVIEW AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103053400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189805700 | ||||||||
| FaxNumber: | 7819805499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 07/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | MANIATIS | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7189805700 | ||||||||
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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 | 207RP1001X | 107251 | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | W07191 | 01 | NY | MEDICARE GROUP | OTHER |