Basic Information
| Provider Information | |||||||||
| NPI: | 1962524447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKAWAY PHYSICIAN PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 529 BEACH 20TH ST | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116913645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183273722 | ||||||||
| FaxNumber: | 7183273294 | ||||||||
| Practice Location | |||||||||
| Address1: | 327 BEACH 19TH ST | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116914423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188697223 | ||||||||
| FaxNumber: | 7188697176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FAMILUSI | ||||||||
| AuthorizedOfficialFirstName: | ABIOLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 7183273722 | ||||||||
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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 | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02593557 | 05 | NY | MEDICAID |