Healthcare Provider Details

I. General information

NPI: 1811505100
Provider Name (Legal Business Name): SHIBRAH M. JAMIL, MD, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11412 BEACH CHANNEL DR STE 10
ROCKAWAY PARK NY
11694-2212
US

IV. Provider business mailing address

15747 ROSE AVE
FLUSHING NY
11355-2327
US

V. Phone/Fax

Practice location:
  • Phone: 718-318-0800
  • Fax:
Mailing address:
  • Phone: 917-975-4163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SHIBRAH JAMIL
Title or Position: PRESIDENT
Credential: MD
Phone: 917-975-4163