Basic Information
Provider Information | |||||||||
NPI: | 1295857092 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEW YORK HOSPITAL QUEENS AMBULANCE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 535 | ||||||||
Address2: |   | ||||||||
City: | BALDWINSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 130270535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009275845 | ||||||||
FaxNumber: | 8009275845 | ||||||||
Practice Location | |||||||||
Address1: | 5645 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FLUSHING | ||||||||
State: | NY | ||||||||
PostalCode: | 113555045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186701231 | ||||||||
FaxNumber: | 7186617942 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2007 | ||||||||
LastUpdateDate: | 05/11/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WARD | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT-CFO | ||||||||
AuthorizedOfficialTelephone: | 7186701476 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 7003010HPF11637 | NY | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 00244133 | 05 | NY |   | MEDICAID |