Healthcare Provider Details

I. General information

NPI: 1750793642
Provider Name (Legal Business Name): SJ ALL MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 N CENTRAL AVE SUITE 3
VALLEY STREAM NY
11580-3856
US

IV. Provider business mailing address

1311 BRIGHTWATER AVE APT 18IJ
BROOKLYN NY
11235-5962
US

V. Phone/Fax

Practice location:
  • Phone: 718-544-4200
  • Fax: 718-544-4201
Mailing address:
  • Phone: 718-544-4200
  • Fax: 718-544-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number StateNY

VIII. Authorized Official

Name: ELLEN EDGAR
Title or Position: PRESIDENT
Credential: MD
Phone: 718-790-7530