Healthcare Provider Details

I. General information

NPI: 1285648154
Provider Name (Legal Business Name): MMC PEDIATRICS FACULTY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

948 48TH STREET
BROOKLYN NY
11219
US

IV. Provider business mailing address

977 48TH ST
BROOKLYN NY
11219-2919
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-8260
  • Fax: 718-283-6147
Mailing address:
  • Phone: 718-283-8015
  • Fax: 718-635-7235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN SHELOV
Title or Position: CHAIRMAN, DEPARTMENT OF PEDIATRICS
Credential: MD
Phone: 718-283-7500