Healthcare Provider Details

I. General information

NPI: 1174575989
Provider Name (Legal Business Name): ELMHURST PODIATRY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8708 JUSTICE AVE SUITE CX
ELMHURST NY
11373-4575
US

IV. Provider business mailing address

8708 JUSTICE AVE SUITE CX
ELMHURST NY
11373-4575
US

V. Phone/Fax

Practice location:
  • Phone: 718-446-4230
  • Fax: 718-457-7015
Mailing address:
  • Phone: 718-446-4230
  • Fax: 718-457-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License NumberN003901
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN003901
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberN003901
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberN003901
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberN003901
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN003901
License Number StateNY
# 7
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN003901
License Number StateNY

VIII. Authorized Official

Name: DR. COLLIER CHAN
Title or Position: PRESIDENT
Credential: DPM
Phone: 718-446-4230