MEDICARE: MEDICAL PRACTICE NY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	185185	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023251261
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL PRACTICE NY PC

Provider Business Mailing Address
First Line	:	5 W 86TH ST APT 1C
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-3663
Country	:	US
Telephone Number	:	212-874-0143
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 W 86TH ST APT 1C
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-3663
Country	:	US
Telephone Number	:	212-874-0143
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. YELENA MAMEDOVA-BRAZ
Credential	:	MD
Telephone Number	:	212-874-0143

Provider Enumeration Date	:	04/17/2009
Last Update Date	:	11/23/2010

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