Provider Demographics
NPI:1053414300
Name:AVENUE U PODIATRY,P.C.
Entity type:Organization
Organization Name:AVENUE U PODIATRY,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GREGG
Authorized Official - Last Name:MARCESE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-996-8420
Mailing Address - Street 1:164 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-3740
Mailing Address - Country:US
Mailing Address - Phone:718-996-8420
Mailing Address - Fax:718-714-6787
Practice Address - Street 1:164 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-3740
Practice Address - Country:US
Practice Address - Phone:718-996-8420
Practice Address - Fax:718-714-6787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2008-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004476213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY480026837OtherRAILROAD MEDICARE
NY01127577Medicaid
NY480026837OtherRAILROAD MEDICARE
NY01127577Medicaid