Provider Demographics
NPI:1871997924
Name:GANGULY ASSOCIATES MD PC
Entity type:Organization
Organization Name:GANGULY ASSOCIATES MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAKHI
Authorized Official - Middle Name:
Authorized Official - Last Name:GANGULY
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:718-379-1800
Mailing Address - Street 1:29 CHICKEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-2103
Mailing Address - Country:US
Mailing Address - Phone:516-759-1661
Mailing Address - Fax:718-320-0749
Practice Address - Street 1:140 BENCHLEY PL FRNT 1
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-3502
Practice Address - Country:US
Practice Address - Phone:718-379-1800
Practice Address - Fax:718-320-0749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147280208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00738376Medicaid
NY1649250812OtherNPI
NY1649250812OtherNPI