Provider Demographics
NPI:1366727869
Name:AVENUE P MEDICAL PC
Entity type:Organization
Organization Name:AVENUE P MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-815-1000
Mailing Address - Street 1:PO BOX 141277
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-1277
Mailing Address - Country:US
Mailing Address - Phone:718-815-1000
Mailing Address - Fax:718-815-8122
Practice Address - Street 1:130 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-6362
Practice Address - Country:US
Practice Address - Phone:718-815-1000
Practice Address - Fax:718-815-8122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148223207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty