Provider Demographics
NPI:1518198944
Name:EVERGREEN MEDICAL CLINIC P.C
Entity Type:Organization
Organization Name:EVERGREEN MEDICAL CLINIC P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNAL MEDICINE
Authorized Official - Prefix:MR
Authorized Official - First Name:YONGKANG
Authorized Official - Middle Name:
Authorized Official - Last Name:HE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-966-8216
Mailing Address - Street 1:351 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-5011
Mailing Address - Country:US
Mailing Address - Phone:212-966-8216
Mailing Address - Fax:212-966-8217
Practice Address - Street 1:77 BOWERY FL 3F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4955
Practice Address - Country:US
Practice Address - Phone:212-966-8216
Practice Address - Fax:212-966-8217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2023389Medicaid