Provider Demographics
NPI:1114100773
Name:UNITED WELLNESS MEDICAL, P.C.
Entity Type:Organization
Organization Name:UNITED WELLNESS MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANTE
Authorized Official - Middle Name:ACEBO
Authorized Official - Last Name:CUBANGBANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-461-5900
Mailing Address - Street 1:3910 MAIN ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5403
Mailing Address - Country:US
Mailing Address - Phone:718-461-5900
Mailing Address - Fax:718-461-4833
Practice Address - Street 1:3910 MAIN ST
Practice Address - Street 2:SUITE 303
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5403
Practice Address - Country:US
Practice Address - Phone:718-461-5900
Practice Address - Fax:718-461-4833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234017208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02623398Medicaid
NY02623398Medicaid
NYI18741Medicare UPIN
NYG100000104Medicare PIN