Provider Demographics
NPI:1093070500
Name:QUEENS NEPHROLOGY PRACTICE, PC
Entity Type:Organization
Organization Name:QUEENS NEPHROLOGY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NARAYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:AGRAWAL
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:347-475-0911
Mailing Address - Street 1:16040 78TH RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1945
Mailing Address - Country:US
Mailing Address - Phone:347-475-0911
Mailing Address - Fax:718-380-3441
Practice Address - Street 1:16040 78TH RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1945
Practice Address - Country:US
Practice Address - Phone:347-475-0911
Practice Address - Fax:718-380-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225128207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02559795Medicaid
I13772Medicare UPIN