Provider Demographics
NPI:1417250168
Name:GREAT WALL MEDICAL PC
Entity Type:Organization
Organization Name:GREAT WALL MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTENDING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HANGJUN
Authorized Official - Middle Name:
Authorized Official - Last Name:JANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:718-321-3962
Mailing Address - Street 1:14627 BEECH AVE # 1C
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2172
Mailing Address - Country:US
Mailing Address - Phone:718-321-3962
Mailing Address - Fax:718-321-3965
Practice Address - Street 1:14627 BEECH AVE # 1C
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2172
Practice Address - Country:US
Practice Address - Phone:718-321-3962
Practice Address - Fax:718-321-3965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty