Basic Information
| Provider Information | |||||||||
| NPI: | 1932641321 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELMHURST SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 565 CONWAY RD | ||||||||
| Address2: | |||||||||
| City: | ELMONT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110033519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184330044 | ||||||||
| FaxNumber: | 7184334644 | ||||||||
| Practice Location | |||||||||
| Address1: | 9422 59TH AVE STE E1 | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113735151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184330044 | ||||||||
| FaxNumber: | 7184334644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2016 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | CREVECOEUR | ||||||||
| AuthorizedOfficialFirstName: | EVANS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7183546810 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.