Basic Information
| Provider Information | |||||||||
| NPI: | 1235199852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON MEDICAL, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7017 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113723922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185655600 | ||||||||
| FaxNumber: | 7185655686 | ||||||||
| Practice Location | |||||||||
| Address1: | 7017 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113723922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185655600 | ||||||||
| FaxNumber: | 7185655686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | KHANDKER | ||||||||
| AuthorizedOfficialFirstName: | FERDOUS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7185655600 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON MEDICAL, PLLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 225253 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02300407 | 05 | NY | MEDICAID |