Basic Information
| Provider Information | |||||||||
| NPI: | 1366460826 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW YORK HOSPITAL MEDICAL CENTER OF QUEENS | ||||||||
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| OtherOrganizationName: | EMERGENCY PRACTICE PLAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 430 | ||||||||
| Address2: | EMERGENCY PRACTICE PLAN | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113520430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106686491 | ||||||||
| FaxNumber: | 6106176280 | ||||||||
| Practice Location | |||||||||
| Address1: | 56-45 MAIN STREET | ||||||||
| Address2: | NYHMQ EMERGENCY DEPARTMENT | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186701426 | ||||||||
| FaxNumber: | 6106176280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SIXSMITH | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPARTMENT CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 7186701426 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00825838 | 05 | NY | MEDICAID |