Provider Demographics
NPI:1316426299
Name:MK HEALTHCARE MEDICAL PC
Entity type:Organization
Organization Name:MK HEALTHCARE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-748-1913
Mailing Address - Street 1:5629 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1975
Mailing Address - Country:US
Mailing Address - Phone:718-418-0300
Mailing Address - Fax:718-418-0301
Practice Address - Street 1:5629 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:718-418-0300
Practice Address - Fax:718-418-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-10
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149503174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00825003Medicaid
NY149503OtherLICENSE