Healthcare Provider Details

I. General information

NPI: 1871908376
Provider Name (Legal Business Name): MEDICAL QUALIFIED SERVICE OF SUFFOLK COUNTY NEW YORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 POTTER BLVD
BRIGHTWATERS NY
11718-1830
US

IV. Provider business mailing address

PO BOX 4059
WAYNE NJ
07474-4059
US

V. Phone/Fax

Practice location:
  • Phone: 973-826-8080
  • Fax: 866-309-3354
Mailing address:
  • Phone: 973-826-8080
  • Fax: 866-309-3354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNY

VIII. Authorized Official

Name: BENJAMIN M SCHWARTZ
Title or Position: MEMBER
Credential: MD
Phone: 973-894-1263