Provider Demographics
NPI:1861561441
Name:S. ADIMOOLAM, PHYSICIAN, PC
Entity type:Organization
Organization Name:S. ADIMOOLAM, PHYSICIAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-494-4934
Mailing Address - Street 1:1756 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3902
Mailing Address - Country:US
Mailing Address - Phone:718-494-3383
Mailing Address - Fax:718-494-1705
Practice Address - Street 1:1756 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3902
Practice Address - Country:US
Practice Address - Phone:718-494-3383
Practice Address - Fax:718-494-1705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYS121313174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0019584OtherGROUP HEALTH INSURANCE
NY00440597Medicaid
NYOC1723OtherPHC
NYOS053OtherOXFORD HEALTH PLANS
NYB11536Medicare UPIN
NY25A413Medicare ID - Type Unspecified
NY25A411Medicare ID - Type Unspecified