Basic Information
| Provider Information | |||||||||
| NPI: | 1033426937 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EHMETH MEDICAL SERVICES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13876 QUEENS BLVD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114352930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188506345 | ||||||||
| FaxNumber: | 7185594895 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 GRAND CONCOURSE | ||||||||
| Address2: | SUITE B5 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104581213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183643322 | ||||||||
| FaxNumber: | 7183642790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2010 | ||||||||
| LastUpdateDate: | 09/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | WALTERS | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERNIST | ||||||||
| AuthorizedOfficialTelephone: | 7183643322 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 115662 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | A300024689 | 01 | NY | MEDICARE EMPIRE | OTHER | G300013444 | 01 | NY | MEDICARE GHI | OTHER | 00213896 | 05 | NY | MEDICAID |