1457410607 NPI number — MASOOM REHAB MEDICAL OFFICE PC

Table of content: (NPI 1457410607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457410607 NPI number — MASOOM REHAB MEDICAL OFFICE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASOOM REHAB MEDICAL OFFICE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457410607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5420 15TH AVE
Provider Second Line Business Mailing Address:
6H
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11219-4352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-287-9406
Provider Business Mailing Address Fax Number:
718-504-7966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79 CHURCH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11218-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-287-9406
Provider Business Practice Location Address Fax Number:
718-504-7966
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IQBAL
Authorized Official First Name:
MOHAMMAD
Authorized Official Middle Name:
ASIF
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
646-287-9406

Provider Taxonomy Codes

  • Taxonomy code: 2081S0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02526350 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07228 . This is a "GHI MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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