MEDICARE: EXECUTIVE MEDICAL CARE,P.C.

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
2	207Q00000X	Family Medicine Physician	222476	NY

General Provider Information

NPI Number	:	1326265885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE MEDICAL CARE,P.C.

Provider Business Mailing Address
First Line	:	42 GOODALL ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-3396
Country	:	US
Telephone Number	:	646-270-8647
Fax Number	:	718-891-7542

Provider Business Practice Location Address
First Line	:	3049 BRIGHTON 6TH STREET
Second Line	:	UNIT CU 1
City	:	BROOKLYN
State	:	NY
Zip	:	11235-6409
Country	:	US
Telephone Number	:	718-934-0322
Fax Number	:	718-934-0994

Authorized Official
Title or Position	:	PRESIDENT , MEDICAL DIRECTOR
Name	:	DR. SERGEY LUGINA
Credential	:	D.O.
Telephone Number	:	646-270-8647

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/26/2024

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