Basic Information
| Provider Information | |||||||||
| NPI: | 1750634911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | P & I DREAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15301 NORTHERN BLVD | ||||||||
| Address2: | SUITE 2D | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113545035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183213210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15301 NORTHERN BLVD | ||||||||
| Address2: | SUITE 2D | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113545035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183213210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2012 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | HYUN | ||||||||
| AuthorizedOfficialFirstName: | JAE | ||||||||
| AuthorizedOfficialMiddleName: | GEUN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7183213210 | ||||||||
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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 | 207RG0100X | 241219 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 03302792 | 05 | NY | MEDICAID |