Provider Demographics
NPI:1174981880
Name:EXCELSIOR INTEGRATED MEDICAL GROUP PLL, DBA EXCELSIOR LABORATORY
Entity type:Organization
Organization Name:EXCELSIOR INTEGRATED MEDICAL GROUP PLL, DBA EXCELSIOR LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:FEI
Authorized Official - Middle Name:
Authorized Official - Last Name:YE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:718-888-0750
Mailing Address - Street 1:4218 162ND ST FL 2
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-4125
Mailing Address - Country:US
Mailing Address - Phone:718-888-0750
Mailing Address - Fax:
Practice Address - Street 1:4218 162ND ST FL 2
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-4125
Practice Address - Country:US
Practice Address - Phone:718-888-0750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33D2094053291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory