Provider Demographics
NPI:1881833713
Name:JACQUES MEDICAL SERVICES PLLC
Entity Type:Organization
Organization Name:JACQUES MEDICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:CARMEL
Authorized Official - Last Name:JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-421-2190
Mailing Address - Street 1:1618 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2418
Mailing Address - Country:US
Mailing Address - Phone:631-421-2190
Mailing Address - Fax:631-421-2695
Practice Address - Street 1:1618 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-2418
Practice Address - Country:US
Practice Address - Phone:631-421-2190
Practice Address - Fax:631-421-2695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199373261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG66052Medicare UPIN