Healthcare Provider Details

I. General information

NPI: 1710543392
Provider Name (Legal Business Name): MATTHEW LIU KERCHEFF PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 BROADWAY
ELMHURST NY
11373-1329
US

IV. Provider business mailing address

7901 BROADWAY
ELMHURST NY
11373-1329
US

V. Phone/Fax

Practice location:
  • Phone: 718-334-2076
  • Fax: 718-334-5006
Mailing address:
  • Phone: 718-334-2076
  • Fax: 718-334-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032283
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: