Provider Demographics
NPI:1356760052
Name:HOLLIS MEDICAL PC
Entity type:Organization
Organization Name:HOLLIS MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MD
Authorized Official - Middle Name:MAHBUBUL
Authorized Official - Last Name:ISLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-480-6882
Mailing Address - Street 1:8786 188TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1131
Mailing Address - Country:US
Mailing Address - Phone:718-480-6882
Mailing Address - Fax:718-217-7653
Practice Address - Street 1:8786 188TH ST
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-1131
Practice Address - Country:US
Practice Address - Phone:718-480-6882
Practice Address - Fax:718-217-7653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02866613Medicaid