Basic Information
| Provider Information | |||||||||
| NPI: | 1578080966 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAMAICA QUEENS PROFESSIONAL MEDICAL SERVICES OF NEW YORK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 WAINWRIGHT DR | ||||||||
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| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600621900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472571244 | ||||||||
| FaxNumber: | 2242468042 | ||||||||
| Practice Location | |||||||||
| Address1: | 16203 JAMAICA AVE UNIT 200A | ||||||||
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| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183011100 | ||||||||
| FaxNumber: | 2242468042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2017 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | KATSNELSON | ||||||||
| AuthorizedOfficialFirstName: | YAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8472571244 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 036105104 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.