Basic Information
| Provider Information | |||||||||
| NPI: | 1902203904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG ISLAND QUEENS MEDICAL, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 947 | ||||||||
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| City: | SYOSSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117910079 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15817 97TH ST | ||||||||
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| City: | HOWARD BEACH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114143228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188455252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2014 | ||||||||
| LastUpdateDate: | 11/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHAH | ||||||||
| AuthorizedOfficialFirstName: | MINAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5164770008 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 189767 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.