Provider Demographics
NPI:1558612762
Name:QUEENS BOULEVARD ASC LLC
Entity Type:Organization
Organization Name:QUEENS BOULEVARD ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AZEEM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-406-8000
Mailing Address - Street 1:95-25 QUEENS BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-0000
Mailing Address - Country:US
Mailing Address - Phone:718-406-8000
Mailing Address - Fax:929-214-4425
Practice Address - Street 1:9525 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4510
Practice Address - Country:US
Practice Address - Phone:718-406-8000
Practice Address - Fax:929-214-4425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-27
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG800091357Medicare PIN