Basic Information
| Provider Information | |||||||||
| NPI: | 1467724666 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCE PROFESSIONAL MEDICAL PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 JAY ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112015150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186466434 | ||||||||
| FaxNumber: | 7183602279 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 JAY ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112015150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186466434 | ||||||||
| FaxNumber: | 7183602279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2012 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | AMOASHIY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7186456434 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 211960 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 01877632 | 05 | NY | MEDICAID |