Provider Demographics
NPI:1770988909
Name:QUEENS NASSAU NEPHROLOGY SERVICES PLLC
Entity type:Organization
Organization Name:QUEENS NASSAU NEPHROLOGY SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONCHARUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-745-0500
Mailing Address - Street 1:300 OLD COUNTRY ROAD
Mailing Address - Street 2:111
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4112
Mailing Address - Country:US
Mailing Address - Phone:516-745-0500
Mailing Address - Fax:516-745-1534
Practice Address - Street 1:300 OLD COUNTRY ROAD
Practice Address - Street 2:111
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4112
Practice Address - Country:US
Practice Address - Phone:516-745-0500
Practice Address - Fax:516-745-1534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03340883Medicaid
NYG100121496Medicare PIN
NYA10002387Medicare PIN