Basic Information
| Provider Information | |||||||||
| NPI: | 1922347673 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAIMONIDES MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MMC BAY PARKWAY PATHOLOGY LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4802 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112192916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182833900 | ||||||||
| FaxNumber: | 7182838796 | ||||||||
| Practice Location | |||||||||
| Address1: | 6010 BAY PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112042567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182838773 | ||||||||
| FaxNumber: | 7182838796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2013 | ||||||||
| LastUpdateDate: | 07/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | CAMMER | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VP, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7182833900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 7001020H | NY | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 00243641 | 05 | NY | MEDICAID |