Healthcare Provider Details

I. General information

NPI: 1740238922
Provider Name (Legal Business Name): MEDIS EAST, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15005 NORTHERN BLVD
FLUSHING NY
11354-3846
US

IV. Provider business mailing address

15005 NORTHERN BLVD
FLUSHING NY
11354-3846
US

V. Phone/Fax

Practice location:
  • Phone: 718-359-5600
  • Fax:
Mailing address:
  • Phone: 718-359-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number02065483
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number02065483
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number02065483
License Number StateNY

VIII. Authorized Official

Name: MR. STANLEY S SUH
Title or Position: PRESIDENT
Credential:
Phone: 718-359-5600