Provider Demographics
NPI:1609015395
Name:PELHAM PKWAY NEUROLOGY AND DIAGNOSTIC, PC
Entity Type:Organization
Organization Name:PELHAM PKWAY NEUROLOGY AND DIAGNOSTIC, PC
Other - Org Name:BROADWAY MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:M
Authorized Official - Last Name:JALAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-620-4246
Mailing Address - Street 1:4114 JUDGE ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2344
Mailing Address - Country:US
Mailing Address - Phone:516-620-4246
Mailing Address - Fax:516-620-6807
Practice Address - Street 1:41-14 JUDGE STREET
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-2344
Practice Address - Country:US
Practice Address - Phone:516-620-4246
Practice Address - Fax:516-620-6807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206287174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01872788Medicaid