Healthcare Provider Details

I. General information

NPI: 1538416466
Provider Name (Legal Business Name): MSU MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 05 169TH STREET
JAMAICA HILLS NY
11432
US

IV. Provider business mailing address

84 05 169TH STREET
JAMAICA HILLS NY
11432
US

V. Phone/Fax

Practice location:
  • Phone: 718-657-8001
  • Fax: 718-732-0783
Mailing address:
  • Phone: 718-657-8001
  • Fax: 718-732-0783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number249483
License Number StateNY

VIII. Authorized Official

Name: DR. MOHAMMED ULLAH
Title or Position: OWNER-PRESIDENT
Credential: MD
Phone: 917-293-3414