Healthcare Provider Details

I. General information

NPI: 1992934467
Provider Name (Legal Business Name): QUEENS NASSAU NEPHROLOGY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2009
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OLD COUNTRY ROAD 111
MINEOLA NY
11501-4112
US

IV. Provider business mailing address

300 OLD COUNTRY ROAD 111
MINEOLA NY
11501-4112
US

V. Phone/Fax

Practice location:
  • Phone: 516-745-0500
  • Fax: 516-745-1534
Mailing address:
  • Phone: 516-745-0500
  • Fax: 516-745-1534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number199896
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateNY

VIII. Authorized Official

Name: DR. ANDREY GONCHARUK
Title or Position: PRESIDENT
Credential: MD
Phone: 516-745-0500