=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245323815
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAPHAEL REISS, A PHYSICIAN P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 07/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 69-05 YELLOWSTONE BLVD.
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-3753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-544-8400
-----------------------------------------------------
Fax | 718-263-5401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 69-05 YELLOWSTONE BLVD.
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-3753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-544-8400
-----------------------------------------------------
Fax | 718-263-5401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAPHAEL REISS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-544-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 133426
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------