Basic Information
| Provider Information | |||||||||
| NPI: | 1184712341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL BROOKLYN MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 SCHERMERHORN ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112171025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184033519 | ||||||||
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| Practice Location | |||||||||
| Address1: | 345 SCHERMERHORN ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112171025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184033519 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAZZA | ||||||||
| AuthorizedOfficialFirstName: | LUCILLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASST COO | ||||||||
| AuthorizedOfficialTelephone: | 7184033519 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 239572 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 239572 | 01 | NY | LIC | OTHER |