MEDICARE: MR. MARC BRADLEY SHAFFREN P.A.

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	363AM0700X	Medical Physician Assistant	000328	NY

General Provider Information

NPI Number	:	1700072089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARC BRADLEY SHAFFREN P.A.

Provider Business Mailing Address
First Line	:	2635 NOSTRAND AVE
Second Line	:	C/O RICHARD SCHWIMMER MD
City	:	BROOKLYN
State	:	NY
Zip	:	11210-4641
Country	:	US
Telephone Number	:	718-252-3622
Fax Number	:	718-253-2513

Provider Business Practice Location Address
First Line	:	2635 NOSTRAND AVE
Second Line	:	C/O RICHARD SCHWIMMER MD
City	:	BROOKLYN
State	:	NY
Zip	:	11210-4641
Country	:	US
Telephone Number	:	718-252-3622
Fax Number	:	718-253-2513

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

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	09/19/2007

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