Provider Demographics
NPI:1326348608
Name:MEDICAL PROFESSIONAL GROUP
Entity Type:Organization
Organization Name:MEDICAL PROFESSIONAL GROUP
Other - Org Name:OMNICARE PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN LIONNEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-433-0044
Mailing Address - Street 1:3110 37TH AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-2112
Mailing Address - Country:US
Mailing Address - Phone:718-433-0044
Mailing Address - Fax:718-433-4644
Practice Address - Street 1:3110 37TH AVE STE 203
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-2112
Practice Address - Country:US
Practice Address - Phone:718-433-0044
Practice Address - Fax:718-433-4644
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OMNICARE PLUS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163744261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service