Provider Demographics
| NPI: | 1770813792 |
|---|---|
| Name: | HICKSVILLE FAMILY MEDICAL CARE, PLLC |
| Entity type: | Organization |
| Organization Name: | HICKSVILLE FAMILY MEDICAL CARE, PLLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | MEDICAL DIRECTOR |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | SANDEEP |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | JAIN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 516-707-8846 |
| Mailing Address - Street 1: | 135 MINEOLA BLVD STE B |
| Mailing Address - Street 2: | |
| Mailing Address - City: | MINEOLA |
| Mailing Address - State: | NY |
| Mailing Address - Zip Code: | 11501-3917 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 917-410-6990 |
| Mailing Address - Fax: | 516-938-1554 |
| Practice Address - Street 1: | 135 MINEOLA BLVD STE B |
| Practice Address - Street 2: | |
| Practice Address - City: | MINEOLA |
| Practice Address - State: | NY |
| Practice Address - Zip Code: | 11501-3917 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 917-410-6990 |
| Practice Address - Fax: | 516-938-1554 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2010-01-14 |
| Last Update Date: | 2025-02-27 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 251E00000X | Agencies | Home Health | Group - Multi-Specialty | |
| No | 251S00000X | Agencies | Community/Behavioral Health | ||
| No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | ||
| No | 261QC1800X | Ambulatory Health Care Facilities | Clinic/Center | Corporate Health | |
| No | 261QE0002X | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | |
| No | 261QH0100X | Ambulatory Health Care Facilities | Clinic/Center | Health Service | |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | |
| No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | |
| No | 261QM1000X | Ambulatory Health Care Facilities | Clinic/Center | Migrant Health | |
| No | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | |
| No | 261QP2400X | Ambulatory Health Care Facilities | Clinic/Center | Prison Health | |
| No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | |
| No | 261QS1000X | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NY | 05716550 | Medicaid |
