Healthcare Provider Details

I. General information

NPI: 1245097989
Provider Name (Legal Business Name): BAY RIDGE MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7404 5TH AVE
BROOKLYN NY
11209-2704
US

IV. Provider business mailing address

7404 5TH AVE
BROOKLYN NY
11209-2704
US

V. Phone/Fax

Practice location:
  • Phone: 929-415-8856
  • Fax: 718-233-3165
Mailing address:
  • Phone: 929-415-8856
  • Fax: 718-233-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN HYUNG IL LEE
Title or Position: OWNER
Credential: MD
Phone: 929-415-8856