Healthcare Provider Details

I. General information

NPI: 1588157788
Provider Name (Legal Business Name): 96TH STREET JUNCTION BLVD MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5548 96TH ST
CORONA NY
11368
US

IV. Provider business mailing address

5548 96TH ST
CORONA NY
11368-3009
US

V. Phone/Fax

Practice location:
  • Phone: 718-606-1199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILDER RUCKER
Title or Position: OWNER
Credential: MD
Phone: 718-606-1199