Basic Information
| Provider Information | |||||||||
| NPI: | 1821093444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETROSSIAN | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000-6600 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191956600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314656297 | ||||||||
| FaxNumber: | 6314656524 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 OLD NORTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115762252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164846777 | ||||||||
| FaxNumber: | 5164840037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 09/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 159502-1 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1047935 | 01 | NY | AETNA USHC-HMO | OTHER | 2198834 | 01 | NY | GHI/FLEX SELECT/PPO | OTHER | 85F031 | 01 | NY | BCBS - PROVIDER I.D. | OTHER | 159502 AND 28446P | 01 | NY | HIP - PROVIDER I.D. | OTHER | 4221943 | 01 | NY | AETNA USHC - NON HMO | OTHER | ZS068 | 01 | NY | OXFORD - PROVIDER I.D. | OTHER | 000000067277 | 01 | NY | GHI/HMO PROVIDER I.D. | OTHER | 1210804 | 01 | NY | UNITED HEALTHCARE | OTHER | 2C8634 | 01 | NY | HEALTHNET - PROVIDER I.D. | OTHER | 05405G | 01 | NY | GHI MEDICARE (QUEENS) | OTHER | 19684 | 01 | NY | VYTRA - PROVIDER I.D. | OTHER | 01848737 | 05 | NY | MEDICAID | 3986056009 | 01 | NY | CIGNA - PROVIDER I.D. | OTHER |