Healthcare Provider Details

I. General information

NPI: 1003322108
Provider Name (Legal Business Name): BLUE NILE MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9408 FLATLANDS AVE
BROOKLYN NY
11236-3742
US

IV. Provider business mailing address

9408 FLATLANDS AVE
BROOKLYN NY
11236-3742
US

V. Phone/Fax

Practice location:
  • Phone: 718-272-0977
  • Fax: 718-272-1088
Mailing address:
  • Phone: 718-272-0977
  • Fax: 718-272-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SEBHATU GEBREZGI
Title or Position: OWNER
Credential: MD
Phone: 718-272-0977