Basic Information
| Provider Information | |||||||||
| NPI: | 1689651226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KMJAN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3656 JOHNSON AVE | ||||||||
| Address2: | SUITE 2B | ||||||||
| City: | RIVERDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104631609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185431877 | ||||||||
| FaxNumber: | 7185436677 | ||||||||
| Practice Location | |||||||||
| Address1: | 3765 RIVERDALE AVE | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | RIVERDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104631845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186014800 | ||||||||
| FaxNumber: | 7186016102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JAN | ||||||||
| AuthorizedOfficialFirstName: | KUNG-MING | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7185431877 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 122967 | NY | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 122967 | NY | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00592374 | 05 | NY | MEDICAID |