Provider Demographics
NPI:1528699873
Name:SIOMS FOREST HILLS MANAGEMENT LLC
Entity type:Organization
Organization Name:SIOMS FOREST HILLS MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:YUSUPOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:516-677-9777
Mailing Address - Street 1:167 FROEHLICH FARM BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:167 FROEHLICH FARM BLVD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2906
Practice Address - Country:US
Practice Address - Phone:516-677-9777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIOMS FOREST HILLS MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03766474Medicaid