Provider Demographics
NPI:1316077068
Name:QUEENS - NY MEDICAL, P.C.
Entity type:Organization
Organization Name:QUEENS - NY MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRONFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-539-3359
Mailing Address - Street 1:4004 BOWNE ST
Mailing Address - Street 2:SUITE 1I
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-6143
Mailing Address - Country:US
Mailing Address - Phone:718-539-3359
Mailing Address - Fax:718-358-3837
Practice Address - Street 1:4004 BOWNE ST
Practice Address - Street 2:SUITE 1I
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6143
Practice Address - Country:US
Practice Address - Phone:718-539-3359
Practice Address - Fax:718-358-3837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02517393Medicaid
NY01580827Medicaid
NY01580827Medicaid
NY06205GMedicare PIN
NY02517393Medicaid
NY06205Medicare PIN
NYY06625Medicare UPIN