Healthcare Provider Details

I. General information

NPI: 1841591153
Provider Name (Legal Business Name): J.S.K. MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 COLUMBUS AVE 3B
NEW YORK NY
10025-3108
US

IV. Provider business mailing address

10248 43RD AVE
CORONA NY
11368-2434
US

V. Phone/Fax

Practice location:
  • Phone: 917-892-9432
  • Fax: 877-721-3255
Mailing address:
  • Phone: 718-779-1900
  • Fax: 718-803-1629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number227598
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number227598
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number227598
License Number StateNY

VIII. Authorized Official

Name: DR. JACOB-SUNG S KEUM
Title or Position: PRESIDENT
Credential: D.O.
Phone: 917-892-9432