1174981880 NPI number — EXCELSIOR INTEGRATED MEDICAL GROUP PLL, DBA EXCELSIOR LABORATORY

Table of content: (NPI 1174981880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174981880 NPI number — EXCELSIOR INTEGRATED MEDICAL GROUP PLL, DBA EXCELSIOR LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCELSIOR INTEGRATED MEDICAL GROUP PLL, DBA EXCELSIOR LABORATORY
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:
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Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1174981880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4218 162ND ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLUSHING
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11358-4125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-888-0750
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4218 162ND ST FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLUSHING
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11358-4125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-888-0750
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
YE
Authorized Official First Name:
FEI
Authorized Official Middle Name:
Authorized Official Title or Position:
LAB MANAGER
Authorized Official Telephone Number:
718-888-0750

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  33D2094053 , 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)





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