1295957652 NPI number — FAR ROCKAWAY MEDICAL PC

Table of content: (NPI 1295957652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295957652 NPI number — FAR ROCKAWAY MEDICAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAR ROCKAWAY 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:
1295957652
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 BEACH 20TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAR ROCKAWAY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11691-3502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-327-5400
Provider Business Mailing Address Fax Number:
718-327-5434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 BEACH 20TH ST
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-686-6700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GABINSKY
Authorized Official First Name:
SERGEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-327-5400

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  199910 , 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: 199910-B79 . This is a "HEALTH FIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4C6779 . This is a "HEALTH NET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 54094N . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P480275 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2546746 . This is a "AETNA HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5227079 . This is a "AETNA PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 534733 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: BK0004505 . This is a "AMERICHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2602083 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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