Provider Demographics
NPI:1285759217
Name:COMMUNITY INTERNAL MEDICINE ASSOC, PC
Entity type:Organization
Organization Name:COMMUNITY INTERNAL MEDICINE ASSOC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-255-2333
Mailing Address - Street 1:9777 QUEENS BLVD
Mailing Address - Street 2:9TH FL STE 900
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9777 QUEENS BLVD
Practice Address - Street 2:9TH FL STE 900
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3317
Practice Address - Country:US
Practice Address - Phone:212-255-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198043207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5816203OtherAETNA