Provider Demographics
NPI:1760533376
Name:UNIVERSAL MEDICAL PRACTICE PC
Entity Type:Organization
Organization Name:UNIVERSAL MEDICAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIDIA
Authorized Official - Middle Name:ROSA
Authorized Official - Last Name:CARRERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-672-1100
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-0270
Mailing Address - Country:US
Mailing Address - Phone:631-264-2035
Mailing Address - Fax:631-264-1418
Practice Address - Street 1:11034 70TH RD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3934
Practice Address - Country:US
Practice Address - Phone:718-672-1100
Practice Address - Fax:718-672-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212687207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02103506Medicaid
NY1H3002Medicare UPIN
NYH10885Medicare ID - Type Unspecified
NY02103506Medicaid