1558520056 NPI number — PRIME CARE MEDICAL OF BRIGHTON PC

Table of content: (NPI 1558520056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558520056 NPI number — PRIME CARE MEDICAL OF BRIGHTON PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME CARE MEDICAL OF BRIGHTON 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:
1558520056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3044 CONEY ISLAND AVE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-934-1499
Provider Business Mailing Address Fax Number:
718-934-1449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3044 CONEY ISLAND AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-934-1499
Provider Business Practice Location Address Fax Number:
718-934-1449
Provider Enumeration Date:
06/09/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SADIQUE
Authorized Official First Name:
IFFAT
Authorized Official Middle Name:
ARA
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
718-934-1400

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  230830 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X , with the licence number: 242628 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: N005475 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02802188 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02585142 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".