Healthcare Provider Details

I. General information

NPI: 1184921371
Provider Name (Legal Business Name): ENDOSCOPIC SURGERY OF NY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10202 QUEENS BLVD
FOREST HILLS NY
11375-3197
US

IV. Provider business mailing address

10202 QUEENS BLVD
FOREST HILLS NY
11375-3197
US

V. Phone/Fax

Practice location:
  • Phone: 718-672-2824
  • Fax:
Mailing address:
  • Phone: 718-672-2824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROM GUPTA
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 718-672-2824