Provider Demographics
NPI:1154789451
Name:ROYAL MEDICAL CENTER FOR WOMEN PC
Entity type:Organization
Organization Name:ROYAL MEDICAL CENTER FOR WOMEN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-221-5001
Mailing Address - Street 1:687 LENOX RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2218
Mailing Address - Country:US
Mailing Address - Phone:718-221-5001
Mailing Address - Fax:718-221-5505
Practice Address - Street 1:3225 FENTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-2801
Practice Address - Country:US
Practice Address - Phone:718-221-5001
Practice Address - Fax:718-221-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272090207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02778018Medicaid
NY02778018Medicaid