Provider Demographics
NPI:1639374390
Name:HOLLIS MEDICAL CARE, P.C.
Entity Type:Organization
Organization Name:HOLLIS MEDICAL CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVYDOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-740-0710
Mailing Address - Street 1:19002 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2516
Mailing Address - Country:US
Mailing Address - Phone:718-740-0710
Mailing Address - Fax:718-740-0755
Practice Address - Street 1:19002 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2516
Practice Address - Country:US
Practice Address - Phone:718-740-0710
Practice Address - Fax:718-740-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02573462Medicaid
NY02724578Medicaid
NY00201583Medicaid
NY06994Medicare ID - Type Unspecified
NY06994GMedicare ID - Type Unspecified
NYB78597Medicare UPIN
NY00201583Medicaid