NPIMap

Organization Active NPI

MK Healthcare Medical PC

  • Specialist
  • Ridgewood, NY
National Provider Identifier
1316426299
Registry record updated Sep 16, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
149503 Issued in NY
Legal business name
MK HEALTHCARE MEDICAL PC
Practice address
5629 Metropolitan Ave
Ridgewood, NY 11385
Phone
(718) 418-0300
Fax
(718) 418-0301
NPI assigned
Aug 10, 2018
Last updated
Sep 16, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 16, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Paul Ambar
Title
Credentialing Manager
Phone
(917) 748-1913

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Specialist 174400000X 149503 NY Primary

Addresses

Primary practice location

5629 Metropolitan Ave
Ridgewood, NY 11385

Mailing address

5629 Metropolitan Ave
Ridgewood, NY 11385-1975
Phone (718) 418-0300

Other identifiers 2

IdentifierTypeStateIssuer
00825003MedicaidNY
149503OtherNYLICENSE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20181025001137 NY Part B Supplier - Clinic/Group Practice 8123371978 Receives reassigned benefits from 11 practitioners
Practice locations: Glen Oaks, NY; Ridgewood, NY

National Provider Directory

National Provider Directory

Locations

5629 Metropolitan Ave
Ridgewood, NY 11385
Phone (718) 418-0300

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1533859200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1663286400000",
    "number": "1316426299",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5629 METROPOLITAN AVE",
            "city": "RIDGEWOOD",
            "state": "NY",
            "postal_code": "113851975",
            "telephone_number": "718-418-0300",
            "fax_number": "718-418-0301"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5629 METROPOLITAN AVE",
            "city": "RIDGEWOOD",
            "state": "NY",
            "postal_code": "11385",
            "telephone_number": "718-418-0300",
            "fax_number": "718-418-0301"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MK HEALTHCARE MEDICAL PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-08-10",
        "last_updated": "2022-09-16",
        "certification_date": "2022-09-16",
        "status": "A",
        "authorized_official_last_name": "AMBAR",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "917-748-1913"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "NY",
            "license": "149503",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00825003",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "149503",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ridgewood, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 16, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.