Basic Information
| Provider Information | |||||||||
| NPI: | 1033206420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | NIDHI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11220 LIBERTY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH RICHMOND HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114191814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185546600 | ||||||||
| FaxNumber: | 5307511237 | ||||||||
| Practice Location | |||||||||
| Address1: | 11220 LIBERTY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH RICHMOND HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114191814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185546600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | EC061109 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A109318 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 291378 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 432702699 | 05 | ME | MEDICAID |