MEDICARE: DR. JIN QIU MD

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	25MA08299200	NJ
2	208D00000X	General Practice Physician	NY198620	NY
3	207Q00000X	Family Medicine Physician	198620	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	134098707	OTHER	NY	TAX ID
2	198620	OTHER	NY	NYS
3	25MA08299200	OTHER	NJ	NJ PRACTICE LOCATION

General Provider Information

NPI Number	:	1801974142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JIN QIU MD

Provider Business Mailing Address
First Line	:	141 E 55TH ST
Second Line	:	SUITE # 10A
City	:	NEW YORK
State	:	NY
Zip	:	10022-4034
Country	:	US
Telephone Number	:	212-758-8851
Fax Number	:	347-527-9166

Provider Business Practice Location Address
First Line	:	141 E 55TH ST STE 4C
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-4050
Country	:	US
Telephone Number	:	212-758-8851
Fax Number	:	347-527-9166

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	01/18/2019

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