Healthcare Provider Details

I. General information

NPI: 1558992206
Provider Name (Legal Business Name): JUNO MEDICAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2020
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2119 FREDERICK DOUGLASS BLVD
NEW YORK NY
10026-2392
US

IV. Provider business mailing address

1485 5TH AVE APT 18C
NEW YORK NY
10035-2778
US

V. Phone/Fax

Practice location:
  • Phone: 212-300-2836
  • Fax:
Mailing address:
  • Phone: 212-300-2836
  • Fax:

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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHANTE HINSON
Title or Position: OWNER
Credential: MD
Phone: 609-320-7998