Basic Information
| Provider Information | |||||||||
| NPI: | 1285198036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW YORK INDIVIDUAL MEDICAL CARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 ROGERS RD | ||||||||
| Address2: | |||||||||
| City: | KINGS POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110242111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165702436 | ||||||||
| FaxNumber: | 5167042058 | ||||||||
| Practice Location | |||||||||
| Address1: | 10201 66TH RD | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113752029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165702436 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2019 | ||||||||
| LastUpdateDate: | 01/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | GOLYAN | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5167758605 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 01959044 | 05 | NY | MEDICAID |