Provider Demographics
NPI:1518008648
Name:SLB MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SLB MEDICAL ASSOCIATES
Other - Org Name:QUEENS VILLAGE MEDICAL PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:SAINT-LAURENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-507-5656
Mailing Address - Street 1:3765 104TH ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-1947
Mailing Address - Country:US
Mailing Address - Phone:718-507-5656
Mailing Address - Fax:718-507-0884
Practice Address - Street 1:9703 SPRINGFIELD BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1328
Practice Address - Country:US
Practice Address - Phone:718-465-7200
Practice Address - Fax:718-465-0407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155418208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00782949Medicaid