Provider Demographics
NPI:1992825772
Name:QUEENS MEDICAL LABORATORY
Entity Type:Organization
Organization Name:QUEENS MEDICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DWORKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-626-4101
Mailing Address - Street 1:1300 UNION TPKE STE 204
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1759
Mailing Address - Country:US
Mailing Address - Phone:516-626-4101
Mailing Address - Fax:516-626-4104
Practice Address - Street 1:43 MINEOLA AVE
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1033
Practice Address - Country:US
Practice Address - Phone:516-626-4101
Practice Address - Fax:516-626-4104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3358291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYL06052Medicare ID - Type Unspecified