1770707622 NPI number — 5000 AVENUE K MEDICAL ASSOCS PC

Table of content: (NPI 1770707622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770707622 NPI number — 5000 AVENUE K MEDICAL ASSOCS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
5000 AVENUE K MEDICAL ASSOCS 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:
1770707622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1987 UTICA AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11234-3225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-629-5590
Provider Business Mailing Address Fax Number:
718-629-2833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 AVENUE K
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:
11234-3225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-968-1515
Provider Business Practice Location Address Fax Number:
718-209-2295
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ACKERMAN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
718-629-5590

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01412986 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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