Provider Demographics
NPI:1598222960
Name:HICKSVILLE PRIMARY MEDICAL CARE PLLC
Entity Type:Organization
Organization Name:HICKSVILLE PRIMARY MEDICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANKUR
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-966-7395
Mailing Address - Street 1:380 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5033
Mailing Address - Country:US
Mailing Address - Phone:516-937-7600
Mailing Address - Fax:718-343-7603
Practice Address - Street 1:380 S BROADWAY
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-5033
Practice Address - Country:US
Practice Address - Phone:516-937-7600
Practice Address - Fax:718-343-7603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY225462OtherLICENSE