MEDICARE: AUSTIN SURGERY PROFESSIONAL GYNECOLOGICAL OFFICE BASED SURGERY

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	261QA1903X	Ambulatory Surgical Clinic/Center	3632	NY

General Provider Information

NPI Number	:	1629368790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN SURGERY PROFESSIONAL GYNECOLOGICAL OFFICE BASED SURGERY

Provider Business Mailing Address
First Line	:	6902 AUSTIN ST
Second Line	:	THIRD FLOOR
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-4233
Country	:	US
Telephone Number	:	718-526-1839
Fax Number	:	718-497-7057

Provider Business Practice Location Address
First Line	:	6902 AUSTIN ST
Second Line	:	THIRD FLOOR
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-4233
Country	:	US
Telephone Number	:	718-526-1839
Fax Number	:	718-497-7057

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ERROL PETER THOMPSON
Credential	:	MD
Telephone Number	:	718-526-1839

Provider Enumeration Date	:	04/11/2011
Last Update Date	:	04/11/2011

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