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General NPI Number Information
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NPI Number | 1053793356
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Entity Type | Organization
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Legal Business Name | NEW YORK SPORTS AND JOINTS ORTHOPAEDIC SPECIALISTS PLLC
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Dates
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Enumeration Date | 06/23/2015
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Last Update Date | 06/23/2015
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Provider Practice Location Address
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Address Line | 6336 99TH ST
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City | REGO PARK
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State | NY
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Zip | 11374-1979
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Country | US
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Telephone | 718-275-1919
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Fax |
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Provider Business Mailing Address
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Address Line | 6336 99TH ST
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City | REGO PARK
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State | NY
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Zip | 11374-1979
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRINCIPAL
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Name | MR. KENNETH MCCULLOCH
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Credential | MD
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Telephone | 718-275-1919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 278501
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License Number State | NY
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