Basic Information
| Provider Information | |||||||||
| NPI: | 1629274972 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AIDS CENTER OF QUEENS COUNTY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACQC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 16121 JAMAICA AVE FL 6 | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114326113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188962500 | ||||||||
| FaxNumber: | 7184596542 | ||||||||
| Practice Location | |||||||||
| Address1: | 16121 JAMAICA AVE FL 6 | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114326113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188962500 | ||||||||
| FaxNumber: | 7184596542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EISENBERG | ||||||||
| AuthorizedOfficialFirstName: | MITCHEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE EXECUTIVE DIRECTOR, ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 7188962500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 8219110A | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 01225456 | 05 | NY | MEDICAID | 01551555 | 05 | NY | MEDICAID |