1992160758 NPI number — LAMD MEDICAL GROUP AND MULTISPECIALTY CORP

Table of content: (NPI 1992160758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992160758 NPI number — LAMD MEDICAL GROUP AND MULTISPECIALTY CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAMD MEDICAL GROUP AND MULTISPECIALTY CORP
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:
6
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:
1992160758
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6506 ROOSEVELT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSIDE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11377-2928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-639-3603
Provider Business Mailing Address Fax Number:
718-639-3605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6506 ROOSEVELT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11377-2928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-639-3603
Provider Business Practice Location Address Fax Number:
718-639-3605
Provider Enumeration Date:
12/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
LOREN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
GEN. OPERATIONAL MANAGER
Authorized Official Telephone Number:
718-639-3603

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  214048 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 33D1043979 . This is a "CLIA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 05593980 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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