Healthcare Provider Details

I. General information

NPI: 1457643991
Provider Name (Legal Business Name): INTERFAITH PROFESSIONAL PHYSICIAN SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 08/12/2024
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 ATLANTIC AVENUE FACULTY PRACTICE
BROOKLYN NY
11213-1122
US

IV. Provider business mailing address

1545 ATLANTIC AVENUE FACULTY PRACTICE
BROOKLYN NY
11213-1122
US

V. Phone/Fax

Practice location:
  • Phone: 718-240-8352
  • Fax: 718-613-4101
Mailing address:
  • Phone: 347-628-4660
  • Fax: 718-613-6422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: GARY STEPHENS
Title or Position: PRESIDENT
Credential: MD
Phone: 718-613-6588