Healthcare Provider Details

I. General information

NPI: 1821314022
Provider Name (Legal Business Name): EMERGENCY PROVIDERS OF IMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 ATLANTIC AVE
BROOKLYN NY
11213-1122
US

IV. Provider business mailing address

1545 ATLANTIC AVE
BROOKLYN NY
11213-1122
US

V. Phone/Fax

Practice location:
  • Phone: 718-613-4000
  • Fax:
Mailing address:
  • Phone: 718-613-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LINDA MOBLEY
Title or Position: DIRECTOR REIMBURSEMENT
Credential:
Phone: 718-613-4000