Basic Information
| Provider Information | |||||||||
| NPI: | 1386051704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RSTNRL MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10614 70TH AVE | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113754253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185206620 | ||||||||
| FaxNumber: | 7185206630 | ||||||||
| Practice Location | |||||||||
| Address1: | 10614 70TH AVE | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113754253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185206620 | ||||||||
| FaxNumber: | 7185206630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | SHAMEEK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2129258882 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 274962 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1720217193 | 01 | NPI | OTHER |