Basic Information
| Provider Information | |||||||||
| NPI: | 1417132390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGSBROOK PRACTICE PLAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 158 W 27TH ST | ||||||||
| Address2: | 11TH FL S | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100016216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125632497 | ||||||||
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| Practice Location | |||||||||
| Address1: | 585 SCHENECTADY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112031809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125632497 | ||||||||
| FaxNumber: | 2125630605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 10/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2125632497 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.