Basic Information
| Provider Information | |||||||||
| NPI: | 1740203686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | SURESH | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 49 HAMILTON DR | ||||||||
| Address2: | |||||||||
| City: | ROSLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115763128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166405669 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13420 JAMAICA AVE | ||||||||
| Address2: | 1ST FL | ||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182066742 | ||||||||
| FaxNumber: | 7182068818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 240921 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 240921 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 1496871 | 05 | LA | MEDICAID |