Basic Information
Provider Information | |||||||||
NPI: | 1528056074 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BREVETTI | ||||||||
FirstName: | TERESA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 777 | ||||||||
Address2: |   | ||||||||
City: | TENAFLY | ||||||||
State: | NJ | ||||||||
PostalCode: | 076700777 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186163440 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2601 OCEAN PKWY | ||||||||
Address2: | CONEY ISLAND HOSPITAL DEPT OF SURGERY | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112357745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186163440 | ||||||||
FaxNumber: | 7186164436 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2005 | ||||||||
LastUpdateDate: | 05/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 215288-1 | NY | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 7955259 | 01 | NY | AETNA PPO ID # | OTHER | 20-0278746 | 01 | NY | TAX ID # | OTHER | 506A91 | 01 | NY | EMPIRE BCBS OF NY ID # | OTHER | 0498091 | 01 | NY | GHI PPO ID # | OTHER | 3622352 | 01 | NY | AETNA HMO ID # | OTHER | 4C8738 | 01 | NY | HEALTHNET ID # | OTHER | P3608471 | 01 | NY | OXFORD ID # | OTHER |