1003250762 NPI number — JACKSON HEIGHTS MEDICAL CARE PC

Table of content: (NPI 1003250762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003250762 NPI number — JACKSON HEIGHTS MEDICAL CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON HEIGHTS MEDICAL CARE 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:
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:
1003250762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7535 31ST AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
EAST ELMHURST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11370-1857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-565-6880
Provider Business Mailing Address Fax Number:
718-565-3102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2008 SEAGIRT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAR ROCKAWAY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11691-2803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-565-6880
Provider Business Practice Location Address Fax Number:
877-796-4457
Provider Enumeration Date:
04/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLEAU
Authorized Official First Name:
CARL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-344-5293

Provider Taxonomy Codes

  • Taxonomy code: 207RS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: G100516770 . This is a "MEDICARE PROVIDER ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 06748732 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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