Provider Demographics
NPI:1851347900
Name:EAST ELMHURST PRIMARY MEDICAL CARE, PLLC
Entity type:Organization
Organization Name:EAST ELMHURST PRIMARY MEDICAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-233-9122
Mailing Address - Street 1:2008 SEAGIRT BLVD
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2803
Mailing Address - Country:US
Mailing Address - Phone:718-565-6880
Mailing Address - Fax:877-796-4457
Practice Address - Street 1:2008 SEAGIRT BLVD
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2803
Practice Address - Country:US
Practice Address - Phone:718-565-6880
Practice Address - Fax:877-796-4457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180270207Q00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01454842Medicaid
NY180270OtherNYS MEDICAL LIC #
NY142AC2Medicare ID - Type UnspecifiedMEDICARE PROVIDER #