Provider Demographics
NPI:1962524447
Name:ROCKAWAY PHYSICIAN PLLC
Entity type:Organization
Organization Name:ROCKAWAY PHYSICIAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:ABIOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAMILUSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-327-3722
Mailing Address - Street 1:529 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3645
Mailing Address - Country:US
Mailing Address - Phone:718-327-3722
Mailing Address - Fax:718-327-3294
Practice Address - Street 1:327 BEACH 19TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4423
Practice Address - Country:US
Practice Address - Phone:718-869-7223
Practice Address - Fax:718-869-7176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02593557Medicaid
NY02593557Medicaid