Provider Demographics
NPI:1538416466
Name:MSU MEDICAL PC
Entity type:Organization
Organization Name:MSU MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-293-3414
Mailing Address - Street 1:84 05 169TH STREET
Mailing Address - Street 2:
Mailing Address - City:JAMAICA HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11432
Mailing Address - Country:US
Mailing Address - Phone:718-657-8001
Mailing Address - Fax:718-732-0783
Practice Address - Street 1:84 05 169TH STREET
Practice Address - Street 2:
Practice Address - City:JAMAICA HILLS
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-657-8001
Practice Address - Fax:718-732-0783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249483174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03019909Medicaid