Provider Demographics
NPI:1033426937
Name:EHMETH MEDICAL SERVICES, PC
Entity Type:Organization
Organization Name:EHMETH MEDICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-364-3322
Mailing Address - Street 1:13876 QUEENS BLVD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2930
Mailing Address - Country:US
Mailing Address - Phone:718-850-6345
Mailing Address - Fax:718-559-4895
Practice Address - Street 1:3130 GRAND CONCOURSE
Practice Address - Street 2:SUITE B5
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-1213
Practice Address - Country:US
Practice Address - Phone:718-364-3322
Practice Address - Fax:718-364-2790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115662207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300024689OtherMEDICARE EMPIRE
NYG300013444OtherMEDICARE GHI
NY00213896Medicaid