Healthcare Provider Details

I. General information

NPI: 1881819308
Provider Name (Legal Business Name): CRYSTAL RAY MEDICAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9614 63RD DR SUITE 200
REGO PARK NY
11374-2239
US

IV. Provider business mailing address

9614 63RD DR SUITE 200
REGO PARK NY
11374-2239
US

V. Phone/Fax

Practice location:
  • Phone: 718-896-0111
  • Fax: 718-896-2161
Mailing address:
  • Phone: 718-896-0111
  • Fax: 718-896-2161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARINA ADELMAN
Title or Position: BILLING DEPARTMENT
Credential:
Phone: 718-743-7090