MEDICARE: QUEENS SURGICAL CENTER LLC

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	1223D0004X	Dental Anesthesiology
2	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1083220123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEENS SURGICAL CENTER LLC

Provider Business Mailing Address
First Line	:	3636 MAIN ST STE 1S
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11354-6517
Country	:	US
Telephone Number	:	347-592-1120
Fax Number	:	800-550-4779

Provider Business Practice Location Address
First Line	:	3636 MAIN ST STE 1S
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11354-6517
Country	:	US
Telephone Number	:	347-592-1120
Fax Number	:	800-550-4779

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. BRIAN S PUN
Credential	:
Telephone Number	:	347-592-1120

Provider Enumeration Date	:	09/22/2020
Last Update Date	:	02/05/2025

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Directions to “QUEENS SURGICAL CENTER LLC ” Practice Location

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