MEDICARE: MARK KIRSCHENBAUM 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	207Q00000X	Family Medicine Physician
2	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1902315161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK KIRSCHENBAUM MEDICAL PC

Provider Business Mailing Address
First Line	:	26 FIREMENS MEMORIAL DR STE 115
Second Line	:
City	:	POMONA
State	:	NY
Zip	:	10970-3569
Country	:	US
Telephone Number	:	845-362-8400
Fax Number	:	845-362-8474

Provider Business Practice Location Address
First Line	:	2361 NOSTRAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-3839
Country	:	US
Telephone Number	:	845-362-8400
Fax Number	:	845-362-8474

Authorized Official
Title or Position	:	MANAGER
Name	:	JOY SHULMAN
Credential	:
Telephone Number	:	800-750-8616

Provider Enumeration Date	:	09/20/2017
Last Update Date	:	09/20/2017

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