Healthcare Provider Details

I. General information

NPI: 1871804062
Provider Name (Legal Business Name): JFK ADVANCED MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JFK AIRPORT BUILDING 75 SUITE 247/249
JAMAICA NY
11430
US

IV. Provider business mailing address

JFK AIRPORT BUILDING 75 SUITE 247/249
JAMAICA NY
11430
US

V. Phone/Fax

Practice location:
  • Phone: 718-656-9500
  • Fax: 718-656-9503
Mailing address:
  • Phone: 718-656-9500
  • Fax: 718-656-9503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number174494-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number212722
License Number StateNY

VIII. Authorized Official

Name: DAVID ROSENTHAL
Title or Position: MANAGER
Credential:
Phone: 718-656-9500