MEDICARE: CARITAS FAMILY HEALTH SERVICES 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	207Q00000X	Family Medicine Physician	171089	NY

General Provider Information

NPI Number	:	1609079870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARITAS FAMILY HEALTH SERVICES PC

Provider Business Mailing Address
First Line	:	11449 SUTPHIN BLVD
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11434-1022
Country	:	US
Telephone Number	:	718-558-7160
Fax Number	:

Provider Business Practice Location Address
First Line	:	11449 SUTPHIN BLVD
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11434-1022
Country	:	US
Telephone Number	:	718-558-7160
Fax Number	:

Authorized Official
Title or Position	:	CHAIRMAN
Name	:	MONTGOMERY DOUGLAS
Credential	:	M.D,
Telephone Number	:	718-558-7160

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	07/31/2008

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