Basic Information
| Provider Information | |||||||||
| NPI: | 1851588990 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLBROOK MEDICAL PRACTICE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 256 | ||||||||
| Address2: | |||||||||
| City: | MILLBROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125450256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456778358 | ||||||||
| FaxNumber: | 8456776205 | ||||||||
| Practice Location | |||||||||
| Address1: | 28 FRONT STREET | ||||||||
| Address2: | |||||||||
| City: | MILLBROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456778358 | ||||||||
| FaxNumber: | 8456776205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2007 | ||||||||
| LastUpdateDate: | 10/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | HAMZA | ||||||||
| AuthorizedOfficialFirstName: | MAHMOUD | ||||||||
| AuthorizedOfficialMiddleName: | IBRAHIM | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 8456778358 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 237858 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 336ANI | 01 | NY | MEDICARE | OTHER |