Basic Information
| Provider Information | |||||||||
| NPI: | 1730439704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUEENS MEDICAL OF NEW YORK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600650032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183011100 | ||||||||
| FaxNumber: | 8886213330 | ||||||||
| Practice Location | |||||||||
| Address1: | 11602 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113757055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183011100 | ||||||||
| FaxNumber: | 8886213330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2012 | ||||||||
| LastUpdateDate: | 09/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | KATSNELSON | ||||||||
| AuthorizedOfficialFirstName: | FLORA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7183011100 | ||||||||
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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 | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2086S0129X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.