Basic Information
| Provider Information | |||||||||
| NPI: | 1972806818 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SATISH TIYYAGURA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 302 MANOR RD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103142408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188151000 | ||||||||
| FaxNumber: | 7188158122 | ||||||||
| Practice Location | |||||||||
| Address1: | 142 JORALEMON STREET | ||||||||
| Address2: | STE 11B | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112014709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188151000 | ||||||||
| FaxNumber: | 7188158122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | TIYYAGURA | ||||||||
| AuthorizedOfficialFirstName: | SATISH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7188151000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 231396 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 231396 | 01 | NY | LIC | OTHER |