MEDICARE: CITYCARE MEDICAL 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1689197451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITYCARE MEDICAL P.C.

Provider Business Mailing Address
First Line	:	4119 18TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11218-5709
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4119 18TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11218-5709
Country	:	US
Telephone Number	:	718-245-6042
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KERILL POCHETUHEN
Credential	:	DO
Telephone Number	:	718-245-6042

Provider Enumeration Date	:	07/24/2017
Last Update Date	:	07/24/2017

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