Provider Demographics
NPI:1386813624
Name:UNIVERSITY PHYSICIANS GROUP PC
Entity type:Organization
Organization Name:UNIVERSITY PHYSICIANS GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:STRANGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-226-1000
Mailing Address - Street 1:65 ROSE AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2246
Mailing Address - Country:US
Mailing Address - Phone:718-979-9333
Mailing Address - Fax:718-980-0408
Practice Address - Street 1:65 ROSE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2246
Practice Address - Country:US
Practice Address - Phone:718-979-9333
Practice Address - Fax:718-980-0408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005325213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty