Provider Demographics
NPI:1861676884
Name:DR. JEROME E. REEVES, DPM, PLLC
Entity Type:Organization
Organization Name:DR. JEROME E. REEVES, DPM, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:E
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-479-5747
Mailing Address - Street 1:8451 BEVERLY RD
Mailing Address - Street 2:2T
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-2123
Mailing Address - Country:US
Mailing Address - Phone:718-441-6271
Mailing Address - Fax:
Practice Address - Street 1:205-07 HILLSIDE AVENUE
Practice Address - Street 2:SUITE 15
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423
Practice Address - Country:US
Practice Address - Phone:718-479-5747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005132332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01502038 1Medicaid
NY01502038 1Medicaid