Basic Information
| Provider Information | |||||||||
| NPI: | 1760533376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSAL MEDICAL PRACTICE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270 | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117620270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312642035 | ||||||||
| FaxNumber: | 6312641418 | ||||||||
| Practice Location | |||||||||
| Address1: | 11034 70TH RD | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113753934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186721100 | ||||||||
| FaxNumber: | 7186727770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 05/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | CARRERO | ||||||||
| AuthorizedOfficialFirstName: | NIDIA | ||||||||
| AuthorizedOfficialMiddleName: | ROSA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7186721100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 212687 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02103506 | 05 | NY | MEDICAID |