MEDICARE: PHYSICIANS MEDICAL GROUP 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	207Q00000X	Family Medicine Physician

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	:	1174500938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS MEDICAL GROUP PC

Provider Business Mailing Address
First Line	:	4303 14TH AVENUE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219
Country	:	US
Telephone Number	:	718-436-7800
Fax Number	:	718-436-6507

Provider Business Practice Location Address
First Line	:	4303 14TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-1429
Country	:	US
Telephone Number	:	718-436-7800
Fax Number	:	718-436-6507

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DAVID WIEDER
Credential	:
Telephone Number	:	718-436-7800

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	08/22/2020

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