Healthcare Provider Details

I. General information

NPI: 1578080966
Provider Name (Legal Business Name): JAMAICA QUEENS PROFESSIONAL MEDICAL SERVICES OF NEW YORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16203 JAMAICA AVE UNIT 200A
JAMAICA NY
11432
US

IV. Provider business mailing address

304 WAINWRIGHT DR
NORTHBROOK IL
60062-1900
US

V. Phone/Fax

Practice location:
  • Phone: 718-301-1100
  • Fax: 224-246-8042
Mailing address:
  • Phone: 847-257-1244
  • Fax: 224-246-8042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036105104
License Number StateIL

VIII. Authorized Official

Name: YAN KATSNELSON
Title or Position: CEO
Credential: MD
Phone: 847-257-1244