Provider Demographics
NPI:1245323815
Name:RAPHAEL REISS, A PHYSICIAN P.C.
Entity type:Organization
Organization Name:RAPHAEL REISS, A PHYSICIAN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:REISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-544-8400
Mailing Address - Street 1:69-05 YELLOWSTONE BLVD.
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3753
Mailing Address - Country:US
Mailing Address - Phone:718-544-8400
Mailing Address - Fax:718-263-5401
Practice Address - Street 1:69-05 YELLOWSTONE BLVD.
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3753
Practice Address - Country:US
Practice Address - Phone:718-544-8400
Practice Address - Fax:718-263-5401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133426174400000X
207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY18905Medicare ID - Type UnspecifiedMEDICARE
NYC07396Medicare UPIN