Healthcare Provider Details

I. General information

NPI: 1649527516
Provider Name (Legal Business Name): LUTHERAN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2012
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 55TH ST DENTAL DEPARTMENT
BROOKLYN NY
11220-2508
US

IV. Provider business mailing address

5800 3RD AVE MANAGED CARE DEPARTMENT
BROOKLYN NY
11220-3702
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-6875
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ASTRID GONZALEZ
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 718-630-8973