Basic Information
| Provider Information | |||||||||
| NPI: | 1861654352 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGS HIGHWAY MEDICAL PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2519 AVENUE O | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112105230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187871900 | ||||||||
| FaxNumber: | 7183825252 | ||||||||
| Practice Location | |||||||||
| Address1: | 2519 AVENUE O | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112105230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187871900 | ||||||||
| FaxNumber: | 7183825252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 05/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | SONI | ||||||||
| AuthorizedOfficialFirstName: | PRABHAT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7187871900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2279C0205X | 192569 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 02236428 | 05 | NY | MEDICAID |