MEDICARE: MR. PETER GREGORY TYSON JR. BA

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	104100000X	Social Worker	100834	NY

General Provider Information

NPI Number	:	1952726283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER GREGORY TYSON JR. BA

Provider Business Mailing Address
First Line	:	590 6TH AVE
Second Line	:	11TH FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10011-2019
Country	:	US
Telephone Number	:	646-300-3213
Fax Number	:	212-660-1344

Provider Business Practice Location Address
First Line	:	848 E 37TH ST APT 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-1937
Country	:	US
Telephone Number	:	347-782-0345
Fax Number	:

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

Provider Enumeration Date	:	02/24/2014
Last Update Date	:	12/11/2025

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