Basic Information
| Provider Information | |||||||||
| NPI: | 1558520056 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME CARE MEDICAL OF BRIGHTON PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3044 CONEY ISLAND AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189341499 | ||||||||
| FaxNumber: | 7189341449 | ||||||||
| Practice Location | |||||||||
| Address1: | 3044 CONEY ISLAND AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189341499 | ||||||||
| FaxNumber: | 7189341449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 09/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | SADIQUE | ||||||||
| AuthorizedOfficialFirstName: | IFFAT | ||||||||
| AuthorizedOfficialMiddleName: | ARA | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7189341400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 242628 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 213E00000X | N005475 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207Q00000X | 230830 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02802188 | 05 | NY | MEDICAID | 02585142 | 05 | NY | MEDICAID |