Healthcare Provider Details

I. General information

NPI: 1053785279
Provider Name (Legal Business Name): MGM MIDWIFERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2015
Last Update Date: 11/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 E 2ND ST
BROOKLYN NY
11218-5604
US

IV. Provider business mailing address

704 E 2ND ST
BROOKLYN NY
11218-5604
US

V. Phone/Fax

Practice location:
  • Phone: 347-894-5223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number001642
License Number StateNY

VIII. Authorized Official

Name: MIRIAM MANDEL
Title or Position: MIDWIFE
Credential:
Phone: 347-894-5223