Provider Demographics
NPI:1043595507
Name:ST ALBANS MEDICAL PC
Entity Type:Organization
Organization Name:ST ALBANS MEDICAL PC
Other - Org Name:ST ALBANS MEDICAL PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUFRENY
Authorized Official - Middle Name:ALPHONSE
Authorized Official - Last Name:GILOUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-413-5665
Mailing Address - Street 1:19912 HOLLIS AVE
Mailing Address - Street 2:1ST FL
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11412-1232
Mailing Address - Country:US
Mailing Address - Phone:718-413-5665
Mailing Address - Fax:718-413-5650
Practice Address - Street 1:199-12 HOLLIS AVENUE
Practice Address - Street 2:1ST FL
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11412-1232
Practice Address - Country:US
Practice Address - Phone:718-413-5665
Practice Address - Fax:718-413-5650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1854231261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy