Provider Demographics
NPI:1790156123
Name:SJ MEDICAL, PLLC
Entity Type:Organization
Organization Name:SJ MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT /ATTENDING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:917-447-4922
Mailing Address - Street 1:1760 2ND AVE
Mailing Address - Street 2:STE. # 22C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031
Mailing Address - Country:US
Mailing Address - Phone:917-447-4922
Mailing Address - Fax:
Practice Address - Street 1:543 W 141ST ST
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-7026
Practice Address - Country:US
Practice Address - Phone:917-447-4922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217144208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5C9901Medicare PIN