Provider First Line Business Practice Location Address: 
27005 76TH AVE
    Provider Second Line Business Practice Location Address: 
ANESTHESIA DEPARTMENT
    Provider Business Practice Location Address City Name: 
NEW HYDE PARK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11040-1496
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-470-7390
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/05/2020