MEDICARE: SOUTH BROOKLYN MEDICAL PRACTICE, 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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1720301989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BROOKLYN MEDICAL PRACTICE, PC

Provider Business Mailing Address
First Line	:	3047 BRIGHTON 6TH ST
Second Line	:	SUITE 2
City	:	BROOKLYN
State	:	NY
Zip	:	11235-6409
Country	:	US
Telephone Number	:	718-743-7877
Fax Number	:	718-743-4870

Provider Business Practice Location Address
First Line	:	3047 BRIGHTON 6TH ST
Second Line	:	SUITE 2
City	:	BROOKLYN
State	:	NY
Zip	:	11235-6409
Country	:	US
Telephone Number	:	718-743-7877
Fax Number	:	718-743-4870

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. DMITRIY BRONFMAN
Credential	:	MD
Telephone Number	:	718-743-7877

Provider Enumeration Date	:	03/02/2010
Last Update Date	:	03/02/2010

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