Provider Demographics
NPI:1083942544
Name:FAMILY HEALTH NURSE PRACTITIONER HOME VISITS PC
Entity Type:Organization
Organization Name:FAMILY HEALTH NURSE PRACTITIONER HOME VISITS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTOV
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:646-201-8985
Mailing Address - Street 1:9605 220TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1347
Mailing Address - Country:US
Mailing Address - Phone:646-201-8985
Mailing Address - Fax:
Practice Address - Street 1:9605 220TH ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1347
Practice Address - Country:US
Practice Address - Phone:646-201-8985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-21
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333427-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02177773Medicaid
NYG100065207OtherMEDICARE PTAN