Provider Demographics
NPI:1851347900
Name:EAST ELMHURST PRIMARY MEDICAL CARE, PLLC
Entity Type:Organization
Organization Name:EAST ELMHURST PRIMARY MEDICAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICOLEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-515-0123
Mailing Address - Street 1:7535 31ST AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1857
Mailing Address - Country:US
Mailing Address - Phone:347-515-0123
Mailing Address - Fax:877-796-4457
Practice Address - Street 1:7535 31ST AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1857
Practice Address - Country:US
Practice Address - Phone:516-755-0390
Practice Address - Fax:516-755-2297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180270207Q00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY180270OtherNYS MEDICAL LIC #
NY180270OtherNYS MEDICAL LIC #
NY142AC2Medicare ID - Type UnspecifiedMEDICARE PROVIDER #