Basic Information
| Provider Information | |||||||||
| NPI: | 1952415846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEHROOZI | ||||||||
| FirstName: | SAEID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1908 RIVER VIEW RD | ||||||||
| Address2: | |||||||||
| City: | GREEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121831139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182713300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | SAMARITAN HOSPITAL | ||||||||
| Address2: | 2215 BURDETT AVE. | ||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182713300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 229512 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207RG0300X | ME98096 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 50147 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001011200 | 05 | FL | MEDICAID |