Provider Demographics
NPI: | 1770813792 |
---|---|
Name: | HICKSVILLE FAMILY MEDICAL CARE, PLLC |
Entity Type: | Organization |
Organization Name: | HICKSVILLE FAMILY MEDICAL CARE, PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MEDICAL DIRECTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | SANDEEP |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | JAIN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 516-707-8846 |
Mailing Address - Street 1: | 1131 W JEFFERSON ST # 365 |
Mailing Address - Street 2: | |
Mailing Address - City: | SHOREWOOD |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60404-0701 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 232 W OLD COUNTRY RD |
Practice Address - Street 2: | |
Practice Address - City: | HICKSVILLE |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11801-4011 |
Practice Address - Country: | US |
Practice Address - Phone: | 917-366-1977 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-01-14 |
Last Update Date: | 2023-06-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 251E00000X | Agencies | Home Health | ||
No | 251S00000X | Agencies | Community/Behavioral Health | ||
No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | ||
No | 261QC1800X | Ambulatory Health Care Facilities | Clinic/Center | Corporate Health | |
No | 261QE0002X | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | |
No | 261QH0100X | Ambulatory Health Care Facilities | Clinic/Center | Health Service | |
No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | |
No | 261QM1000X | Ambulatory Health Care Facilities | Clinic/Center | Migrant Health | |
No | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | |
No | 261QP2400X | Ambulatory Health Care Facilities | Clinic/Center | Prison Health | |
No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | |
No | 261QS1000X | Ambulatory Health Care Facilities | Clinic/Center | Student Health | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 01925539 | Medicaid |