Healthcare Provider Details

I. General information

NPI: 1720178486
Provider Name (Legal Business Name): QLIMG LAKE SUCCESS/NEW HYDE PARK MED. OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ZECKENDORF BLVD
GARDEN CITY NY
11530-2133
US

IV. Provider business mailing address

1991 MARCUS AVE 2ND FLOOR
NEW HYDE PARK NY
11042-2057
US

V. Phone/Fax

Practice location:
  • Phone: 516-355-5800
  • Fax: 516-355-5877
Mailing address:
  • Phone: 516-354-1600
  • Fax: 516-941-4672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARLENA SIMPSON
Title or Position: DIRECTOR OF CREDENTIALING
Credential: CPMSM
Phone: 516-542-6880