Provider Demographics
NPI:1720040629
Name:NEW YORK IMMUNOLOGY PC
Entity Type:Organization
Organization Name:NEW YORK IMMUNOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-793-9020
Mailing Address - Street 1:6920 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1703
Mailing Address - Country:US
Mailing Address - Phone:718-793-9020
Mailing Address - Fax:
Practice Address - Street 1:6920 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1703
Practice Address - Country:US
Practice Address - Phone:718-793-9020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184552173000000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01694724Medicaid
NY01694724Medicaid
NYF42512Medicare UPIN