1932146339 NPI number — DR. ANITA GROSS MOALLEM MD

Table of content: DR. ANITA GROSS MOALLEM MD (NPI 1932146339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932146339 NPI number — DR. ANITA GROSS MOALLEM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOALLEM
Provider First Name:
ANITA
Provider Middle Name:
GROSS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1932146339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
560 S BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HICKSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11801-5027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-933-2800
Provider Business Mailing Address Fax Number:
516-933-2809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4355 147TH ST
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:
11355-1736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-762-0900
Provider Business Practice Location Address Fax Number:
718-886-5659
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  095345 , 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: 10459014 . This is a "CAQH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00549293 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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