Basic Information
| Provider Information | |||||||||
| NPI: | 1023063526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROOKLYN MEDICAL ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3534 BROOKLYN AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468091361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607476171 | ||||||||
| FaxNumber: | 2604785125 | ||||||||
| Practice Location | |||||||||
| Address1: | 3534 BROOKLYN AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468091361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607476171 | ||||||||
| FaxNumber: | 2604785125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 12/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8778929813 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207Q00000X | 50000594A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100284760C | 05 | IN | MEDICAID |