Provider Demographics
NPI:1316289853
Name:AMERICAN COMPREHENSIVE HEALTHCARE MEDICAL GROUP. PC
Entity type:Organization
Organization Name:AMERICAN COMPREHENSIVE HEALTHCARE MEDICAL GROUP. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
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:718-688-8000
Mailing Address - Street 1:5205 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-3513
Mailing Address - Country:US
Mailing Address - Phone:718-688-8000
Mailing Address - Fax:718-688-8081
Practice Address - Street 1:5205 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3513
Practice Address - Country:US
Practice Address - Phone:718-688-8000
Practice Address - Fax:718-688-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03109400Medicaid