Provider Demographics
NPI:1326158536
Name:QUEENS PROFESSIONAL MEDICAL CARE,P.C.
Entity Type:Organization
Organization Name:QUEENS PROFESSIONAL MEDICAL CARE,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-599-4475
Mailing Address - Street 1:58 BUCKINGHAM PL
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-1835
Mailing Address - Country:US
Mailing Address - Phone:516-599-4475
Mailing Address - Fax:516-599-2185
Practice Address - Street 1:11110 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2322
Practice Address - Country:US
Practice Address - Phone:516-599-4475
Practice Address - Fax:516-599-2185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG01008Medicare UPIN
NY06173Medicare ID - Type UnspecifiedGHI MEDICARE