Provider Demographics
NPI:1689745424
Name:ADVANCED MEDICAL CARE PLLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-261-8068
Mailing Address - Street 1:10124 QUEENS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2703
Mailing Address - Country:US
Mailing Address - Phone:718-261-8881
Mailing Address - Fax:718-261-8889
Practice Address - Street 1:10124 QUEENS BLVD STE A
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2703
Practice Address - Country:US
Practice Address - Phone:718-261-8881
Practice Address - Fax:718-261-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207UN0901X, 2084N0400X
NY009605363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01908598Medicaid
NY02851334Medicaid
NY03098Medicare ID - Type Unspecified