1790995991 NPI number — QUEENS BRONX MEDICAL P.C

Table of content: (NPI 1790995991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790995991 NPI number — QUEENS BRONX MEDICAL P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUEENS BRONX MEDICAL P.C
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:
1790995991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4102 31ST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASTORIA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11103-3420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-274-6100
Provider Business Mailing Address Fax Number:
718-665-1746

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4102 31ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11103-3420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-274-6100
Provider Business Practice Location Address Fax Number:
718-665-1746
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALLA
Authorized Official First Name:
VIJAY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-274-6100

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  211067 , 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: VA0184AK10 . This is a "EMPIRE BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01914447 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06864G . This is a "GHI MEDICARE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1000003667 . This is a "AFFINITY HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2511884 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 06864 . This is a "NY GHI MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 211067C19 . This is a "HEALTHFIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AV1067 . This is a "ATLANTIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1P1158 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00006049401 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 171389 . This is a "ELDERPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 211067 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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