=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740447119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUEENSWEST MEDICAL, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2008
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4301 BROADWAY
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-2359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-274-4200
-----------------------------------------------------
Fax | 718-204-4933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4301 BROADWAY
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-2359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-274-4200
-----------------------------------------------------
Fax | 718-204-4933
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MINZALIA ZOUBTSOVA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-274-4200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 241143
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------