=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710363577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUEENS WELLNESS MEDICAL CARE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2015
-----------------------------------------------------
Last Update Date | 08/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125-07 101 AVENUE
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11419-1411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-713-7672
-----------------------------------------------------
Fax | 718-450-9384
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125-07 101 AVENUE
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11419-1411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-713-7672
-----------------------------------------------------
Fax | 718-806-1435
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | MS. RITA JHAVERI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 516-713-7672
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 192697
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------