MEDICARE: GREENE AVENUE MEDICAL, 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	261QP2300X	Primary Care Clinic/Center	157407	NY

General Provider Information

NPI Number	:	1811431323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENE AVENUE MEDICAL, PC

Provider Business Mailing Address
First Line	:	1350 GREENE AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11237-4902
Country	:	US
Telephone Number	:	718-628-8216
Fax Number	:	718-628-4755

Provider Business Practice Location Address
First Line	:	1350 GREENE AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11237-4902
Country	:	US
Telephone Number	:	718-628-8216
Fax Number	:	718-628-4755

Authorized Official
Title or Position	:	PRESIDENT/TRUSTEE
Name	:	ELIDE STERLIN
Credential	:
Telephone Number	:	570-972-7511

Provider Enumeration Date	:	12/19/2016
Last Update Date	:	12/19/2016

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