Healthcare Provider Details

I. General information

NPI: 1043124563
Provider Name (Legal Business Name): EXCELSIOR UROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11203 QUEENS BLVD STE 204
FOREST HILLS NY
11375-5550
US

IV. Provider business mailing address

11203 QUEENS BLVD STE 204
FOREST HILLS NY
11375-5550
US

V. Phone/Fax

Practice location:
  • Phone: 718-902-0877
  • Fax: 716-779-3262
Mailing address:
  • Phone: 718-902-0877
  • Fax: 716-779-3262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: RUBEN PINKHASOV
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 646-407-9791