Provider Demographics
NPI:1871707372
Name:9317 MEDICAL OFFICE PC
Entity type:Organization
Organization Name:9317 MEDICAL OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARRERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-446-0270
Mailing Address - Street 1:9317 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7943
Mailing Address - Country:US
Mailing Address - Phone:718-446-0270
Mailing Address - Fax:718-446-5939
Practice Address - Street 1:9317 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7943
Practice Address - Country:US
Practice Address - Phone:718-446-0270
Practice Address - Fax:718-446-5939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01748636Medicaid
FL121841700Medicaid