MEDICARE: FOREST HILLS PSYCHIATRIC PC

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	103TC2200X	Clinical Child & Adolescent Psychologist	016036	NY
2	2084P0800X	Psychiatry Physician	159418	NY
3	1041C0700X	Clinical Social Worker	R056338	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	016036	OTHER	NY	DR MINI POTHEN LICENSE#
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	159418	OTHER	NY	DR. RASOOL LICENSE#

General Provider Information

NPI Number	:	1437218674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOREST HILLS PSYCHIATRIC PC

Provider Business Mailing Address
First Line	:	76-03 113TH STREET
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6585
Country	:	US
Telephone Number	:	718-268-1100
Fax Number	:	718-263-6418

Provider Business Practice Location Address
First Line	:	76-03 113TH ST
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6585
Country	:	US
Telephone Number	:	718-268-1100
Fax Number	:	718-268-6418

Authorized Official
Title or Position	:	PSYCHIATRIST
Name	:	SHAMA RASOOL
Credential	:	MD
Telephone Number	:	718-268-1100

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	05/07/2014

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