Provider Demographics
NPI:1538340203
Name:JIANJUN LI GI MEDICAL PC
Entity type:Organization
Organization Name:JIANJUN LI GI MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WINNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-567-8808
Mailing Address - Street 1:730 58TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3917
Mailing Address - Country:US
Mailing Address - Phone:718-567-8808
Mailing Address - Fax:718-567-8820
Practice Address - Street 1:730 58TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3917
Practice Address - Country:US
Practice Address - Phone:718-567-8808
Practice Address - Fax:718-567-8820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244434174400000X
NY257725174400000X
NJ25MA08744000174400000X
NJ25MA09606000174400000X
NJ25MA09610400174400000X
NY203883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02577640Medicaid
NYG94129Medicare UPIN
NY02577640Medicaid