Basic Information
Provider Information | |||||||||
NPI: | 1295194504 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRIGHTON BEACH MEDICAL OF NEW YORK, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 304 WAINWRIGHT DR | ||||||||
Address2: |   | ||||||||
City: | NORTHBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 600621900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8472571244 | ||||||||
FaxNumber: | 2242468042 | ||||||||
Practice Location | |||||||||
Address1: | 2965 OCEAN PKWY | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112358014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7183011100 | ||||||||
FaxNumber: | 2242468042 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2016 | ||||||||
LastUpdateDate: | 02/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KATSNELSON | ||||||||
AuthorizedOfficialFirstName: | FLORA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8472571244 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.