Basic Information
| Provider Information | |||||||||
| NPI: | 1396728986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKDALE PLAZA NEPHROLOGY ASSOC. PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKDALE PLAZA NEPHROLOGY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BROOKDALE PLZ | ||||||||
| Address2: | ROOM 169CHC | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182405615 | ||||||||
| FaxNumber: | 7184854064 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BROOKDALE PLZ | ||||||||
| Address2: | ROOM 169CHC | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182405615 | ||||||||
| FaxNumber: | 7184854064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHOU | ||||||||
| AuthorizedOfficialFirstName: | SHYAN-YIH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7182405615 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 0011077 | 01 | NY | GHI | OTHER | 00429410 | 05 | NY | MEDICAID | 0087129 | 01 | NY | AETNA US HEALTHCARE | OTHER |