Provider Demographics
NPI:1386719557
Name:PREMIUM MEDICAL OF NEW YORK PC
Entity type:Organization
Organization Name:PREMIUM MEDICAL OF NEW YORK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGIOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-463-2630
Mailing Address - Street 1:147-09 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:718-463-2630
Mailing Address - Fax:
Practice Address - Street 1:147-09 ELM AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-463-2630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1937884173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01685730Medicaid
NY37255VMedicare ID - Type Unspecified
NY01685730Medicaid