MEDICARE: PHOENIX MEDICAL CENTER INC

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

General Provider Information

NPI Number	:	1912007063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	29 STEVEN LN
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11024-1534
Country	:	US
Telephone Number	:	718-386-1100
Fax Number	:

Provider Business Practice Location Address
First Line	:	341 KNICKERBOCKER AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11237-3740
Country	:	US
Telephone Number	:	718-386-1100
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	SOSHANA CITRIN
Credential	:
Telephone Number	:	718-386-1100

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	04/03/2012

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