Provider Demographics
NPI:1164614590
Name:QUEENS VILLAGE PRIMARY MEDICAL CARE, PLLC
Entity Type:Organization
Organization Name:QUEENS VILLAGE PRIMARY MEDICAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ARYEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-465-3040
Mailing Address - Street 1:9204 SPRINGFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1857
Mailing Address - Country:US
Mailing Address - Phone:718-465-3040
Mailing Address - Fax:718-464-9063
Practice Address - Street 1:9204 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1857
Practice Address - Country:US
Practice Address - Phone:718-465-3040
Practice Address - Fax:718-464-9063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141741261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00587146Medicaid
NY06974Medicare PIN