=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033549639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANJEEV JAIN PHYSICIAN P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2013
-----------------------------------------------------
Last Update Date | 12/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10810 72ND AVE 4TH FLOOR
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-5338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-544-7950
-----------------------------------------------------
Fax | 718-544-7951
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24738 77TH CRES
-----------------------------------------------------
City | BELLEROSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11426-1863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-457-9348
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF
-----------------------------------------------------
Name | DR. SANJEEV JAIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 516-457-9348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 225429
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------