Healthcare Provider Details

I. General information

NPI: 1235580218
Provider Name (Legal Business Name): THG ROOSEVELT ENDOSCOPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13668 ROOSEVELT AVE FL 3
FLUSHING NY
11354-5510
US

IV. Provider business mailing address

15 OAK DR
GREAT NECK NY
11021-1809
US

V. Phone/Fax

Practice location:
  • Phone: 718-886-9819
  • Fax:
Mailing address:
  • Phone: 718-886-9819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number256797
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number256797
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number256797
License Number StateNY

VIII. Authorized Official

Name: DR. TONG JING
Title or Position: PRESIDENT
Credential: M.D.
Phone: 718-886-9819