Provider Demographics
NPI:1639212939
Name:WESTERN QUEENS DIALYSIS
Entity Type:Organization
Organization Name:WESTERN QUEENS DIALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP - REMIBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:GURKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-312-3034
Mailing Address - Street 1:2314 COLLEGE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-2526
Mailing Address - Country:US
Mailing Address - Phone:347-312-3034
Mailing Address - Fax:347-312-3042
Practice Address - Street 1:3401 35TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-1222
Practice Address - Country:US
Practice Address - Phone:718-707-9988
Practice Address - Fax:718-707-9830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7001256A261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02167953Medicaid
NY332618Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER