Basic Information
| Provider Information | |||||||||
| NPI: | 1477505220 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAMAICA HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JAMAICA HOSPITAL EMERGENCY DEPARTMENT - RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 MARCUS DR | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPT. | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313917797 | ||||||||
| FaxNumber: | 6314544163 | ||||||||
| Practice Location | |||||||||
| Address1: | 8900 VAN WYCK EXPWY | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182068918 | ||||||||
| FaxNumber: | 6314544163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 04/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | DOSS | ||||||||
| AuthorizedOfficialFirstName: | MOUNIR | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 7182405773 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 207PE0004X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 01616320 | 05 | NY | MEDICAID |