MEDICARE: SOUTH QUEENS NEPHROLOGY ASSO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician

General Provider Information

NPI Number	:	1003809245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH QUEENS NEPHROLOGY ASSO

Provider Business Mailing Address
First Line	:	175-37 LIBERTY AVE
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11433-1325
Country	:	US
Telephone Number	:	718-297-9100
Fax Number	:	718-297-0625

Provider Business Practice Location Address
First Line	:	34-35 70TH STREET
Second Line	:
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372
Country	:	US
Telephone Number	:	718-651-9700
Fax Number	:	718-533-0264

Authorized Official
Title or Position	:	NEPHROLOGY
Name	:	MRS. EVELYN RUZOL AMARGA
Credential	:	MD
Telephone Number	:	718-651-9700

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	08/22/2020

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