Basic Information
| Provider Information | |||||||||
| NPI: | 1861148058 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEARNEY | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 417 EVANS AVE | ||||||||
| Address2: | |||||||||
| City: | ELMONT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110033309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318979519 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27005 76TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184707000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2022 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 1180700 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.