Provider Demographics
NPI:1922017789
Name:QUEENS MEDICAL OFFICE, P.C.
Entity Type:Organization
Organization Name:QUEENS MEDICAL OFFICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-458-1515
Mailing Address - Street 1:4046 74TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5602
Mailing Address - Country:US
Mailing Address - Phone:718-458-1515
Mailing Address - Fax:718-458-0397
Practice Address - Street 1:4046 74TH ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5602
Practice Address - Country:US
Practice Address - Phone:718-458-1515
Practice Address - Fax:718-458-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209191207Q00000X
NY177471207Q00000X
NY149657207Q00000X
NY261999207Q00000X
NY187566207R00000X, 207RP1001X
NY162464207R00000X
NY167446207R00000X
NY008399363AM0700X
NY013504363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05870Medicare PIN
X95289Medicare UPIN