Provider Demographics
NPI:1477862191
Name:IMMUNIZATION MEDICAL SERVICES PC
Entity type:Organization
Organization Name:IMMUNIZATION MEDICAL SERVICES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SAYEGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP
Authorized Official - Phone:914-376-7000
Mailing Address - Street 1:235 HEMBREE PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5738
Mailing Address - Country:US
Mailing Address - Phone:770-512-8566
Mailing Address - Fax:770-512-8558
Practice Address - Street 1:909 MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10704-1092
Practice Address - Country:US
Practice Address - Phone:770-512-8566
Practice Address - Fax:770-512-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227084207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02458313Medicaid
NYI0345PMedicare UPIN
NY02458313Medicaid