MEDICARE: CENTRAL BROOKLYN MEDICAL GROUP

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	207VX0000X	Obstetrics Physician	239572	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	239572	OTHER	NY	LIC

General Provider Information

NPI Number	:	1184712341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL BROOKLYN MEDICAL GROUP

Provider Business Mailing Address
First Line	:	345 SCHERMERHORN ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11217-1025
Country	:	US
Telephone Number	:	718-403-3519
Fax Number	:

Provider Business Practice Location Address
First Line	:	345 SCHERMERHORN ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11217-1025
Country	:	US
Telephone Number	:	718-403-3519
Fax Number	:

Authorized Official
Title or Position	:	ASST COO
Name	:	MS. LUCILLE MAZZA
Credential	:
Telephone Number	:	718-403-3519

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	08/22/2020

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