1093019440 NPI number — MARIA LUCIA JIMENEZ, MA,PT,PC

Table of content: (NPI 1093019440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093019440 NPI number — MARIA LUCIA JIMENEZ, MA,PT,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIA LUCIA JIMENEZ, MA,PT,PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093019440
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9131 QUEENS BLVD
Provider Second Line Business Mailing Address:
SUITE 314
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11373-5501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-205-3435
Provider Business Mailing Address Fax Number:
718-205-2402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9131 QUEENS BLVD
Provider Second Line Business Practice Location Address:
SUITE 314
Provider Business Practice Location Address City Name:
ELMHURST
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11373-5501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-205-3435
Provider Business Practice Location Address Fax Number:
718-205-2402
Provider Enumeration Date:
12/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JIMENEZ
Authorized Official First Name:
M. LUCIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
718-205-3435

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  024486 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9008690 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: Q072P1 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03245654 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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