Provider Demographics
NPI:1124659479
Name:SIOMS FOREST HILLS MANAGEMENT LLC
Entity type:Organization
Organization Name:SIOMS FOREST HILLS MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:YUSUPOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:718-261-2790
Mailing Address - Street 1:7009 AUSTIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7009 AUSTIN ST STE 201
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1012
Practice Address - Country:US
Practice Address - Phone:718-261-2790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIOMS FOREST HILLS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03766474Medicaid