=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376010769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NASSAU QUEENS MEDICAL CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2018
-----------------------------------------------------
Last Update Date | 10/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7535 31ST AVENUE SUITE 205
-----------------------------------------------------
City | EAST ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-316-6870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7535 31ST AVE STE 205
-----------------------------------------------------
City | EAST ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11370-1846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-316-6870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. DEBORAH EISEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 347-307-1449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------