Basic Information
| Provider Information | |||||||||
| NPI: | 1366567414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADULT AND GERIATRIC MEDICAL CARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 157 BEAUMONT ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112354118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9176094748 | ||||||||
| FaxNumber: | 7186303761 | ||||||||
| Practice Location | |||||||||
| Address1: | 4802 10TH AVE FL 10 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112192916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9176095537 | ||||||||
| FaxNumber: | 7186303761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEVINA | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9176095537 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 234232 | NY | N | Ambulatory Health Care Facilities | Clinic/Center | 207RG0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03416084 | 05 | NY | MEDICAID |