Provider Demographics
NPI:1770696650
Name:MARIANNE MEDICAL SERVICE P.C
Entity type:Organization
Organization Name:MARIANNE MEDICAL SERVICE P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMALINI
Authorized Official - Middle Name:
Authorized Official - Last Name:ASIRWATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-448-6034
Mailing Address - Street 1:665 CLOVE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2737
Mailing Address - Country:US
Mailing Address - Phone:718-448-6034
Mailing Address - Fax:718-448-5396
Practice Address - Street 1:19 SCHERMERHORN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-448-6034
Practice Address - Fax:718-448-5396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231851174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02730312Medicaid
NY148090Medicare UPIN
NY02730312Medicaid