Provider Demographics
NPI:1659487460
Name:UNION TURNPIKE MEDICAL PC
Entity type:Organization
Organization Name:UNION TURNPIKE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHESINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-380-0011
Mailing Address - Street 1:15034 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3928
Mailing Address - Country:US
Mailing Address - Phone:718-380-0011
Mailing Address - Fax:718-820-0841
Practice Address - Street 1:15034 UNION TPKE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3928
Practice Address - Country:US
Practice Address - Phone:718-380-0011
Practice Address - Fax:718-820-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203378207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG36928Medicare UPIN