Provider Demographics
NPI:1003250762
Name:JACKSON HEIGHTS MEDICAL CARE PC
Entity type:Organization
Organization Name:JACKSON HEIGHTS MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICHOLEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-344-5293
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:718-565-6880
Mailing Address - Fax:718-565-3102
Practice Address - Street 1:2008 SEAGIRT BLVD
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2803
Practice Address - Country:US
Practice Address - Phone:718-565-6880
Practice Address - Fax:877-796-4457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG100516770OtherMEDICARE PROVIDER ID
NY06748732Medicaid