Healthcare Provider Details

I. General information

NPI: 1750566584
Provider Name (Legal Business Name): HOLLIS HILLS MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21715 PECK AVE
QUEENS VILLAGE NY
11427-1117
US

IV. Provider business mailing address

21715 PECK AVE
QUEENS VILLAGE NY
11427-1117
US

V. Phone/Fax

Practice location:
  • Phone: 718-217-2705
  • Fax: 718-217-2708
Mailing address:
  • Phone: 718-217-2705
  • Fax: 718-217-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number222374
License Number StateNY

VIII. Authorized Official

Name: DR. ROXANA RUIZCARO-CHAVEZ
Title or Position: ASSOCIATE DIRECTOR
Credential: MD
Phone: 718-217-2705