1205004181 NPI number — SMB MEDICAL, PC

Table of content: (NPI 1205004181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205004181 NPI number — SMB MEDICAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMB MEDICAL, 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:
1205004181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9522 63RD RD
Provider Second Line Business Mailing Address:
#531
Provider Business Mailing Address City Name:
REGO PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11374-1142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-271-3548
Provider Business Mailing Address Fax Number:
718-606-0719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9522 63RD RD
Provider Second Line Business Practice Location Address:
531
Provider Business Practice Location Address City Name:
REGO PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11374-1142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-271-3548
Provider Business Practice Location Address Fax Number:
718-606-0719
Provider Enumeration Date:
02/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BAYNER
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-271-3548

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  231488 , 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: 231488 . This is a "LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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