Healthcare Provider Details

I. General information

NPI: 1083220123
Provider Name (Legal Business Name): QUEENS SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 MAIN ST STE 1S
FLUSHING NY
11354-6517
US

IV. Provider business mailing address

3636 MAIN ST STE 1S
FLUSHING NY
11354-6517
US

V. Phone/Fax

Practice location:
  • Phone: 347-592-1120
  • Fax: 800-550-4779
Mailing address:
  • Phone: 347-592-1120
  • Fax: 800-550-4779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN S PUN
Title or Position: MANAGING MEMBER
Credential:
Phone: 347-592-1120