MEDICARE: DR. LIN GONG M.D.

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	207R00000X	Internal Medicine Physician	224112	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	:	1063483311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LIN GONG M.D.

Provider Business Mailing Address
First Line	:	763 56TH ST STE 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3529
Country	:	US
Telephone Number	:	718-567-3667
Fax Number	:	718-567-2332

Provider Business Practice Location Address
First Line	:	763 56TH ST FL 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3503
Country	:	US
Telephone Number	:	718-567-3667
Fax Number	:	718-567-2332

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	04/18/2012

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