Healthcare Provider Details

I. General information

NPI: 1235608035
Provider Name (Legal Business Name): EASTERN MEDICAL CONSULTING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W 58TH ST
NEW YORK NY
10019-1827
US

IV. Provider business mailing address

25 WILLET AVE
HICKSVILLE NY
11801-1637
US

V. Phone/Fax

Practice location:
  • Phone: 212-765-6470
  • Fax: 212-333-7346
Mailing address:
  • Phone: 347-744-8605
  • Fax: 516-935-3140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: GLENN JAKOBSEN
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 347-744-8605