Provider Demographics
NPI:1750470514
Name:ISLAND OF HEALTH MEDICAL PC
Entity Type:Organization
Organization Name:ISLAND OF HEALTH MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-554-5735
Mailing Address - Street 1:8002 165 ST. UNION TNPK
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432
Mailing Address - Country:US
Mailing Address - Phone:718-380-7000
Mailing Address - Fax:212-791-3388
Practice Address - Street 1:8002 165 ST. UNION TNPK
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-380-7000
Practice Address - Fax:212-791-3388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215006261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02091596Medicaid
NY04255Medicare ID - Type Unspecified
NY02091596Medicaid