Provider Demographics
NPI:1174928378
Name:AMERICAN COMPREHENSIVE HEALTHCARE MEDICAL GROUP
Entity type:Organization
Organization Name:AMERICAN COMPREHENSIVE HEALTHCARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-688-8088
Mailing Address - Street 1:5205-7 CHURCH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-0386
Mailing Address - Country:US
Mailing Address - Phone:718-688-8088
Mailing Address - Fax:718-688-8081
Practice Address - Street 1:5205-7 CHURCH AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3513
Practice Address - Country:US
Practice Address - Phone:718-688-8088
Practice Address - Fax:718-688-8018
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 Licenses
StateLicense IDTaxonomies
NY002201207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002778018Medicaid
NY002201OtherLICENSE
NY002201OtherLICENSE