Provider Demographics
NPI:1194048058
Name:ULTIMATE PRIMARY CARE PC
Entity type:Organization
Organization Name:ULTIMATE PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOUEL-ELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-833-4742
Mailing Address - Street 1:254 BIRCHWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2307
Mailing Address - Country:US
Mailing Address - Phone:718-833-4742
Mailing Address - Fax:718-836-4629
Practice Address - Street 1:9711 3RD AVE
Practice Address - Street 2:BSMT LEVEL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7702
Practice Address - Country:US
Practice Address - Phone:718-833-4742
Practice Address - Fax:718-836-4629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238713174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03080206Medicaid