Provider Demographics
NPI:1346562949
Name:FIRST RIVERSIDE MEDICAL CARE P.C.
Entity Type:Organization
Organization Name:FIRST RIVERSIDE MEDICAL CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:XIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-661-4800
Mailing Address - Street 1:4242 COLDEN ST
Mailing Address - Street 2:SUITE L17
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-4855
Mailing Address - Country:US
Mailing Address - Phone:718-661-4800
Mailing Address - Fax:718-888-2701
Practice Address - Street 1:4242 COLDEN ST
Practice Address - Street 2:SUITE L17
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-4855
Practice Address - Country:US
Practice Address - Phone:718-661-4800
Practice Address - Fax:718-888-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219846207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02129591Medicaid
NYH31353Medicare UPIN