=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033452008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUEENS MIDLAND MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2013
-----------------------------------------------------
Last Update Date | 08/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8675 MIDLAND PKWY
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-523-2177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 LAKE DR
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040-1123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SUCHETA D MAHAJAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-523-2177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 60153553
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 60128659
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 60100118
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 60136232
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------