NPIMap

Organization Active NPI

SG Medical Professional PC

  • Family Medicine Physician
  • Staten Island, NY
National Provider Identifier
1457085615
Registry record updated May 30, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SG MEDICAL PROFESSIONAL PC
Practice address
260 Christopher LN Ste 102a
Staten Island, NY 10314-1631
Phone
(718) 362-1405
Fax
(718) 414-1651
NPI assigned
Jul 13, 2022
Last updated
May 30, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 30, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dov Hollander
Title
Director of Operations
Phone
(631) 759-9920

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

260 Christopher LN Ste 102a
Staten Island, NY 10314-1631

Mailing address

45 S Route 9W Unit 41 #114
West Haverstraw, NY 10993-1053
Phone (631) 759-9920

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY, FL, TX, CT4 enrollments

Enrollment records 4

Enrollment IDStateProvider typePAC IDDetails
O20250506001217 NY Part B Supplier - Clinic/Group Practice 9133646953 Receives reassigned benefits from 21 practitioners
Practice locations: Syracuse, NY; Staten Island, NY; Rockaway Park, NY; New York, NY; Holbrook, NY; Freeport, NY; Brooklyn, NY; Bronx, NY…
O20260206001751 FL Part B Supplier - Clinic/Group Practice 9133646953 Receives reassigned benefits from 16 practitioners
Practice locations: Boca Raton, FL
O20260319003961 TX Part B Supplier - Clinic/Group Practice 9133646953 Receives reassigned benefits from 1 practitioner
Practice locations: Round Rock, TX
O20260324002230 CT Part B Supplier - Clinic/Group Practice 9133646953 Receives reassigned benefits from 3 practitioners
Practice locations: Stamford, CT

National Provider Directory

National Provider Directory

Locations

21067 Powerline Rd 57
Boca Raton, FL 33433

21067 Powerline Rd 57
Boca Raton, FL 33433

220 Park Ave
Thomasville, GA 31792
Phone (229) 227-0880

1298 Coates Ave
Holbrook, NY 11741
Phone (631) 475-8819

Practitioners & affiliated clinicians

Practitioners 42

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 42

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1657670400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748563200000",
    "number": "1457085615",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "45 S ROUTE 9W UNIT 41 #114",
            "city": "WEST HAVERSTRAW",
            "state": "NY",
            "postal_code": "109931053",
            "telephone_number": "631-759-9920",
            "fax_number": "315-612-9793"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "260 CHRISTOPHER LN STE 102A",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103141631",
            "telephone_number": "718-362-1405",
            "fax_number": "718-414-1651"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SG MEDICAL PROFESSIONAL PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-07-13",
        "last_updated": "2025-05-30",
        "certification_date": "2025-05-30",
        "status": "A",
        "authorized_official_last_name": "HOLLANDER",
        "authorized_official_first_name": "DOV",
        "authorized_official_title_or_position": "DIRECTOR OF OPERATIONS",
        "authorized_official_telephone_number": "631-759-9920"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Staten Island, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 30, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.