1972774990 NPI number — GOOD HEALTH MEDICAL OF BROOKLYN, P.C.

Table of content: (NPI 1972774990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972774990 NPI number — GOOD HEALTH MEDICAL OF BROOKLYN, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOD HEALTH MEDICAL OF BROOKLYN, P.C.
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:
1972774990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2026 OCEAN AVE
Provider Second Line Business Mailing Address:
SUITE 1B
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11230-7352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-645-9236
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2026 OCEAN AVE
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11230-7352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-645-9236
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
YANKILEVICH
Authorized Official First Name:
LEO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-645-9236

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  199964 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1018720 . This is a "FIDELIS CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 432740N . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 87093 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01601192 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 199964 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2C9154 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 005908 . This is a "METROPLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 45J051 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 137603 . This is a "WELCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P683045 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: N130940 . This is a "1199" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10111 . This is a "ELDERPALN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2597940 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 45J051 . This is a "MAGNACARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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