Provider Demographics
NPI:1760731459
Name:FIVE STAR MEDICAL OFFICE PC
Entity Type:Organization
Organization Name:FIVE STAR MEDICAL OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP REVENUE MANAGEMENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-553-3591
Mailing Address - Street 1:PO BOX 801280
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1280
Mailing Address - Country:US
Mailing Address - Phone:718-576-4652
Mailing Address - Fax:516-710-7846
Practice Address - Street 1:10407 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6735
Practice Address - Country:US
Practice Address - Phone:718-576-4652
Practice Address - Fax:516-710-7846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265676207R00000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03477218Medicaid