Provider Demographics
NPI:1104142082
Name:STATEN ISLAND MEDICAL PRACTICE, P.C.
Entity type:Organization
Organization Name:STATEN ISLAND MEDICAL PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIANS' ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARCHETTA
Authorized Official - Suffix:
Authorized Official - Credentials:RPA
Authorized Official - Phone:718-948-5475
Mailing Address - Street 1:5405 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5241
Mailing Address - Country:US
Mailing Address - Phone:718-948-5475
Mailing Address - Fax:718-948-5479
Practice Address - Street 1:5405 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5241
Practice Address - Country:US
Practice Address - Phone:718-948-5475
Practice Address - Fax:718-948-5479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191751261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
11177655OtherCAQH
NY01860833Medicaid
11177655OtherCAQH
G59515Medicare UPIN