1457410607 NPI number — MASOOM REHAB MEDICAL OFFICE PC

Table of Contents

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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