=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235338138
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMON LIPETZ MD. P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2007
-----------------------------------------------------
Last Update Date | 07/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104-60 QUEENS BLVD SUITE CH
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-275-4849
-----------------------------------------------------
Fax | 718-275-6381
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104-60 QUEENS BLVD. SUITE CH
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-275-4849
-----------------------------------------------------
Fax | 718-275-6381
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SIMON LIPETZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-275-4849
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | 458751
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | 107463
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | 186190
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------