Basic Information
Provider Information | |||||||||
NPI: | 1134594955 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AJS BROOKYLN MEDICAL PRACTICE PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6255 W SUNSET BLVD FL 21 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900287422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3238605200 | ||||||||
FaxNumber: | 8332417615 | ||||||||
Practice Location | |||||||||
Address1: | 161-21 JAMAICA AVE | ||||||||
Address2: | 7TH FLOOR | ||||||||
City: | JAMAICA | ||||||||
State: | NY | ||||||||
PostalCode: | 11432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7188962500 | ||||||||
FaxNumber: | 7184598515 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2015 | ||||||||
LastUpdateDate: | 09/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STIDHAM | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF, MANAGED CARE | ||||||||
AuthorizedOfficialTelephone: | 3234365025 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.