Provider Demographics
NPI:1437494648
Name:MEDICAL PRACTICE NY PC
Entity Type:Organization
Organization Name:MEDICAL PRACTICE NY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMEDOVA BRAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-755-0656
Mailing Address - Street 1:95-20 63 RD ROAD SUITE H
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:347-813-4143
Mailing Address - Fax:
Practice Address - Street 1:6923 168TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-3213
Practice Address - Country:US
Practice Address - Phone:718-755-0656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185185103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01274024Medicaid